Anti-retroviral Treatment Implementation Status & Outcome ...

Federal HIV/AIDS Prevention & Control Office

Addis Ababa, Ethiopia [2013]

Anti-retroviral Treatment Implementation Status & Outcome Study in Ethiopia

ART Implementation Status and Outcome Study in Ethiopia 2013

Page 1

INVESTIGATORS

Eleni Seyuom (BSc, MPH), FHAPCO/WHO

Gurmesa Tura (BSc, MPH), Jimma University

Yifiru Brehan (MD, Gynecologist), Hawassa University

Lemessa Oligira (BSc, MPH), Haramaya University

Dejene Hailu (BSc, Mphil, Hawassa University

Solomon Gebremariam (MD, MPH),Mekele University

Yemane Asheber (BSc, MPH), Mekele University

Neway Hiruy (MD, MPH), Mekele University

Tariku Dingata (BSc, Mphil), Hawassa University

Yeshambel Belayhun (BSc, MSc), University of Gondar,

Abreham Alano (BSc, MPH), Hawassa University

Desalegn Zegeye Desalegn (MD, MPH), University of Gondar,

Yibeltal Assefa (MD, MSc), FHAPCO


Page 2

ACKNOWLEDGMENT

The successes the ART program has shown in Ethiopia, as depicted by various reports and

by the findings of the study as well, are the results of strong national ownership and

leadership, active community engagement, and unprecedented international support in the

delivery of life saving interventions. Taking this opportunity, we would like to express our

appreciation and thanks to all who have made contributions in attaining encouraging results.

In particular, we would like to acknowledge the Global Fund to Fight AIDS, Tuberculosis

and Malaria, and PEPFAR for their marked contributions to the national response. Also our

thanks and appreciation goes to the UN family, bilateral organizations, NGOs, FBOs, PLHIV

associations, CSOs, CBOs, the private sector, media and communities at large who made

their part in the fight against HIV and AIDS in the country.

FHAPCO extends its deep and special appreciation to all investigators who directly were

engaged in conducting this huge study. We would like to thank the task force members who

provided the necessary technical support at various stages of the study.

The expense of the study was covered by WHO Ethiopia, and thus FHAPCO would like to

acknowledge WHO Ethiopia for covering the cost of this study, in addition to its

engagement in providing technical support in conducting the study. We are also grateful to the

AIDS resource center (ARC) for the material and technical support they provided during the study

period.

FHAPCO would like to appreciate Regional HAPCOs and Health Bureaus, Ministry of

Defense as well as the Directors and service providers of the health facilities that took part

in the study for their valuable support throughout the study process in their respective

health facilities. We also greatly thank the participants of the study for their participation

and contributions, without them the study couldn‟t materialize.

Our Appreciation goes to Dr. Thomas Heller of CDC Ethiopia who provided technical support

particularly on editing the document, Dr. Yared Mekonnen for his support on the data analysis of the

study, as well as to Dr. Belete Tegbaru, Ato Alemayheu Mekonnen, and Dr. Nega Assefa for their

participation as field supervisors.

Finally we thank all the data collectors, exit interview participants, in-depth interview participants,

and all others whose names are not listed for their unreserved contributions.

Ato Berhanu Feyisa

Director General, Federal HAPCO


Page 3

TASKFORCE MEMBERS

Dr. Yibeltal Assefa - FHAPCO Chairman

Mrs. Eleni Seyoum - FHAPCO/WHO Member

Dr. Achamyeleh Alebachew - FHAPCO/WHO “

Dr. Thomas Heller - CDC – Ethiopia “

Dr. Solomon Ahmed - CDC – Ethiopia “

Dr. Thomas Kenyon - CDC-Ethiopia “

Prof. Sileshi Lulseged - ICAP-Ethiopia “

Dr. Zenebe Melaku - ICAP-Ethiopia “

Dr. Kassu Ketema - WHO “

Dr. Innocent Ntaganira - WHO “

Dr. Helina Worku - USAID “

Dr. Manuel Kassaye - I-Tech Ethiopia “

Dr. Degu Jerene - JHU –Ethiopia “

Ms. Kanchan Reed - PEPFAR US Embassy “

Mr. Raphael Hurlay - Clinton Foundation “

Dr. Yigeremu Abebe - Clinton Foundation “

Dr. Khynn Win Win Soe - UNICEF “

Dr. Christine Sadie - UNAIDS “


Page 4

TABLE OF CONTENT

CONTENT PAGE

Acknowledgment ii

Table of content iii

Lists of figures V

Lists of tables Vi

Acronyms Vii

Executive Summary Viii

CHAPTER I: INTRODUCTION 1

1.1 Background 1

1.1.1 HIV/AIDS situation in Ethiopian 1

1.1.2 Overview of ART program in Ethiopia 2

1.2 Rationale of the study 4

1.3 Study questions and objectives 4

1.3.1 Study questions 4

1.3.2 Study objectives 4

CHAPTER 2: METHODOLOGY 5

2.1 Study area and period 5

2.2 Study design 5

2.3 Population 5

2.3.1 Source population 5

2.3.2 Study population 6

2.4 Inclusion and exclusion criteria 6

2.4.1 Inclusion criteria 6

2.4.2 Exclusion criteria 6

2.5 Sample size determination and sampling techniques 7

2.5.1 Sample size determination 7

2.5.2 Sampling techniques 7

2.6 Data collection process 8

2.6.1 Measurements (study variables) 8

2.6.2 Data collection tools 8

2.6.3 Pretest 9

2.6.4 Data collectors and supervisors 9

2.6.5 Training of data collectors 9

2.6.6 Data collection procedure 9

2.7 Data analysis 10

2.8 Data quality control 10

2.9 Ethical clearance 10

2.10 Operational definition of terms 11


Page 5

CHAPTER 3: RESULT 12

3.1 ART patients‟ treatment outcome from medical record review 12

3.1.1 Background characteristics of ART patients at enrolment 13

3.1.2 Biological and clinical characteristics of ART patients at

Enrollment

14

3.1.3 Survival and retention rate among ART clients 15

3.1.4 Attrition rate among ART clients 16

3.1.5 Immunological treatment outcome among ART patients 22

3.1.6 Clinical and biological treatment outcome among ART patients 25

3.1.7 ART program performance at ART enrolment 26

3.1.8 Predictors of ART patients‟ „survival and lost/drop 29

3.2 ART patients‟ drug regimen pattern and adherence from medical

record

30

3.2.1 First and second line ARV drug regimen use 35

3.2.2 ART drug regimen change 36

3.2.3 Adherence to care and treatment 37

3.3 ART Service Quality in Ethiopia 39

3.3.1 Findings from facility observation 39

3.3.2 Findings of ART clients exit interview 40

3.4 Community perception about ART and its impacts 42

3.4.1 Perception about HIV/AIDS burden 42

3.4.2 Perception about care and support 42

3.4.3 Perception about ART access and use 42

3.4.4 Perception about effects of ART 43

CHAPTER 4: PROGRAM IMPLICATIONS 44

CHAPTER 5: CONCLUSIONS & RECOMMENDATIONS 47

ANNEXES: 50

REFERENCE 61


Page 6

L ISTS OF F IGURES

Figure 1 Survival rate of HIV patients who started ART from Sept. 2005- May

2010

16

Figure 2 Retention rates of HIV patients who started ART from Sept. 2005 -

May 2010

17

Figure 3 Retention rates of HIV patients by start year of cohort and

treatment duration

18

Figure 4 Retention rate among HIV patients after 12 months of ART initiation

by age and sex

19

Figure 5 Retention rate for HIV patients by regional distribution for the

cohort of

2005/6 – 2009/2010

20

Figure 6 Retention rate for HIV patients by residence and type of health

facilities for the cohort year of 2005/6–2009/10

21

Figure 7 Proportion of death and lost/dropout rates by year of cohort, 2005/6

to 2009/10

23

Figure 8 Time of death and lost to follow up among ART users among the

cohort of 2005/6-2009/10

24

Figure 9 Mean CD4 + count among ART patients who are still alive and on

treatment

25

Figure10 Functional status among ART patients who are still alive and on

treatment

26

Figure 11 Mean weights of adult ART patients who are still alive and on

treatment

27

Figure 12 Prevalence of anemia among adult ART patients who are still alive

and on treatment

28

Figure 13 Prevalence of anemia among children < 15 year ART patients who

are still alive and on treatment

28

Figure 14 Functional status, WHO staging and CD4 + count at enrollment of

HIV patients

29

Figure 15 Survival between female & male 31

Figure 16 Survival by functional status 31

Figure 17 Survival by CD4 + count 31

Figure 18 Survival by WHO staging 31

Figure 19 Patterns of ART drug regimens among ART users who are still alive

and on drug after 60 months start of ART

35

Figure 20 Patterns of drug regimen change and proportion of patients who

developed toxicity

36

Figure 21 Clinic appoint keeping among ART patients alive and on ART, and

among those who subsequently were lost to follow or died

37

Figure 22 Early warning indicators in Ethiopia (2005/6-2010/11) and globally

suggested targets

38


Page 7

L ISTS OF TABLES

Table 1 Selected socio-demographic characteristics of HIV patients on

ART at enrollment

13

Table 2 Biological and clinical characteristics of HIV patients at ART

enrollment

15

Table 3 Attrition among HIV patients after initiation of ART by region,

2005/6 – 2009/2010

22

Table 4 Hazard Ratio (HR) of Cox Proportional Hazards model and 95%

CI interval in the estimation of the risk of death according to

selected characteristics of patients at enrollment (age 15+)

32


CI interval in the estimation of the risk of death according to

selected characteristics of patients at enrollment among children

age 0-14 years

33


CI interval in the estimation of the risk of lost to follow up (lost,

dead or stopped) according to selected characteristics of patients

at enrollment (adults 15+)

34


Page 8

ACRONYMS

AIDS Acquired Immunodeficiency Syndrome

ART Anti-Retroviral Therapy

ARV Anti-Retroviral

AZT Zidovudine

CBC Complete Blood Count

CBO Community Based Organization

CD4 Cluster Differentiation cell 4

CDC Center for Disease Control

CI Confidence Interval

CSO Civil Society Organization

EDHS Ethiopian Demographic and Health survey

EFV Efavirenz

FBO Faith Based Organization

FHAPCO Federal HIV/AIDS Prevention and Control Office

FMOH Federal Ministry of Health

HAPCO HIV/AIDS Prevention and Control Office

Hgb Hemoglobin

HR Hazard ratio

HF Health Facility

HIV Human Immunodeficiency Virus

ICT Information Communication Technology

LTFU Lost To Follow Up

MD Medical Doctor

MOH Ministry of Health

NGO Non-governmental Organization

NVP Neverapin

OI Opportunistic Infection

OSSA Organization for Social Services for AIDS

PEP Post Exposure Prophylaxis

PICT Provider Initiated Counseling and Testing

PMTCT Prevention of Mother to Child Transmission

PLHIV People Living with HIV

SNNPR Southern Nations, Nationalities and Peoples‟ Region

TB Tuberculosis

TLC Total Lymphocyte Count

TO Transferred Out

VCT Volunteer Counseling and Testing

WHO World Health Organization

3TC Lamivudine


Page 9

EXECUTIVE SUMMARY

Background: In response to the epidemic, the government of Ethiopia formulated the National

HIV/AIDS policy in 1998. To realize the commitment in the implementation of the policy, the

government has taken many steps; among which the introduction of free ART service in 2005 takes

the greatest share. Since then, the government has played active role, together with partners, to

increase the number and distribution of health facilities providing antiretroviral therapy by all people

at all levels. As a result, the ART service coverage and its uptake in the country have shown dramatic

improvement. However, despite eight years of free service and high coverage, its level of

effectiveness as measured by patient survival and overall improvement in health status among those

treated has not been comprehensively addressed at a national level. Therefore, this study has been

conducted to achieve the following objectives.

Objectives:

1. To determine ART patient treatment outcomes in Ethiopia

2. To determine the pattern of ARV drug regimen and adherence

3. To assess the status of ART service quality

4. To assess perception of the community towards ART and its impact in reducing death

caused by AIDS.

Methods: Cross sectional and retrospective cohort study designs that involved both quantitative

and qualitative data collection methods were used. To determine ART patient outcomes

(Objective 1), a five year retrospective cohort study (follow up) of patients‟ conditions was made,

sampling more than 42,200 adult records in a random fashion from a representative number of

treatment facilities, as well as all 7,375 pediatric records from these facilities. Pattern of ARV drug

regimen and adherence (objective 2) was also determined from the retrospective record review

and supplemented by in-depth interviews of service providers and case managers, as well as client

exit interviews. To assess the status of ART service quality (objective 3), facility audits were

conducted at a representative sample of facilities to determine available human resources, facilities‟

functional features (running water, electricity, etc), equipment, and supplies using an observation

checklist. In addition, client exit interviews were done to assess the process of service delivery from

clients‟ perspective and client satisfaction perspective.

Perception of the community about ART and its impact (objective 4) was assessed by conducting

in-depth interviews with selected community members such as health extension workers, religious

leaders and iddir leaders.


Page 10

To assure a representative sampling of treatment sites from all regions of the country as well as high,

medium, and low volume sites, a multi-stage sampling method was used, with hospital sites randomly

selected after grouping by region and patient volume.

Health centers were chosen randomly from among those providing ART in the catchment area of

the selected hospitals. At each facility, charts were reviewed based on a random sampling technique

of all patients ever enrolled in care between September 2005 and May 2010.

Key findings: The ultimate goal of ART is to reduce HIV related morbidity and mortality and to

improve quality of life, to restore and preserve immunologic function, and to maximally and durably

suppress viral load. From the perspective of the clinical and immunological goals, the following

patient outcomes were observed after five years of ART interventions in Ethiopia.

Finding from the medical record review

The five years survival rate for Ethiopia is found to be 78% (based on the worst case scenario).

To evaluate the five years survival analysis, three scenarios are considered. The best-case

scenario assumed drop and lost to follow up patients are alive, the worst-case scenario assumed

drop is dead and lost is alive and in the midpoint scenario transfer out, drop and lost were

excluded from the analysis.

12 months retention rate after initiation of ART is 82.4%.

Improvement in 12 months retention rate has been observed over the last five years; from 80%

in 2005/6 to 83.4% in 2009/2010.

Most recent 24 month, 36 month, and 48 month retention rates were 79.7%, 76.9% , and 75%,

respectively.

Retention rate is highest (87%) in Tigray and lowest (70%) in Afar regions.

Better survival and retention rates are observed among Children <15 years; and among adults,

survival and retention are better for women compared to men.

Immunological response improved after six months on ART among patients who were still alive

and on treatment, with CD4 counts more than doubling over the first twelve months (increasing

from a mean of 145 to 328) of initiation, and continued to increase over the course of the

follow-up period.

Improvement in quality of life is also observed. On average, ART patients gained 10% (5-6kgs) of

their baseline weight at six months and a slight increment was observed over subsequent

treatment periods.

Ethiopia‟s ART program has demonstrated progress over time in initiating patients earlier in the

course of their disease, as assessed by WHO staging, baseline CD4 count, and functional status.


Page 11

In Year 2009/10, 40% of HIV patients started ART at WHO stage 1 or 2 as compared to 15% in

2005/6.

Likewise, mean CD4 count at time of ART initiation increased from 137 to 199 from 2005/6 to

2009/10, and over the same time period the percent of patients starting ART while in working

condition increased from 50% to 67%.

Most importantly, 12 months mortality has decreased from 8.9% among patients on ART in

2005/6 to 5.8% in 2009/10.

The ART drug regimen-switch rate from 1st line to 2nd line was 2% after five years on treatment

which is very slow as compared to other resource limited countries (11)

Early treatment intervention, as assessed by baseline CD4 count, WHO staging, and functional

status at enrollment was the main predictor of survival.

ART program inputs from observation study:

ART and related guidelines were not available in 22% of visited health facilities and not observed

in an additional 27% of the facilities.

Baseline CD4 cell count had been determined for patients in nearly all facilities (done on-site at

46% and through sample transfer in 54% of facilities).

Nearly half of the observed health facilities do not perform key laboratory tests. For example,

CBC, renal function test, liver function test and hepatitis B antigen test were being done in 40%,

49%, 50% and 49% of the visited health facilities respectively during the time of the survey.

Conclusions: In general, although the ART program in Ethiopia has been performing well, the facility

audit found that there are significant gaps in resources (inputs) for ART service implementation

including unavailability of necessary guidelines, unavailability, and non-functionality of some

laboratory studies. This study also revealed that there is remarkable improvement in program

performance of ART at enrollment, depicted by WHO disease staging, mean CD4 cell count,

functional status at enrollment which have shown significant improvement over years.

Recommendations:

Policy level:

Availing necessary guidelines at different levels; MOH and key stakeholders to make sure

nationally produced HIV/AIDS related guidelines are disseminated and distributed at regional,

woreda, and health facility levels.

Establish better mechanism for clinical, immunological monitoring, and increase performance of

viral load tests to identify treatment failure on time.

Program level:


Page 12

Identify strategy for determining adherence to treatment other than self-report; further

investigations should be conducted to assess reasons for regimen-shift;

Facility level:

Perform key required laboratory tests (Haemoglobin test, liver and kidney function tests) based

on the national ART guidelines;

Improve identification of treatment failure and report periodically;

Strengthen adherence counselling with strong focus among male, young HIV patients in order to

improve the adherence level among these groups;

Improve the current ART patient card handling system to avoid long waiting time and loss of

patient cards;

Develop and implement Quality Control Tools for facilities to monitor the quality of services

they are providing.

Community level: Ensure community involvement and active participation in the program, with

particular emphasis on addressing stigma and discrimination and its impacts; Train community

counselors (with local language); Create better mechanisms for nutritional support for needy ART

patients;


Page 13

CHAPTER -1: INTRODUCTION

1 .1 Ba ckground

1.1.1 HIV/AIDS situation in Ethiopia

With a population estimate of nearly 84 million in 2012, Ethiopia is the second largest populous and

the least (16%) urbanized country in Africa. Youth population constitutes more than one third of the

population in the country (1). Ethiopia is a federal republic system and politically administered by

nine regional national states and two city administrations. The Federal Ministry of Health (FMOH) is

responsible for the overall coordination of the national health system in the country. Under the

leadership of FMOH, the Federal HIV/AIDS Prevention and Control Office (FHAPCO) coordinates,

mobilizes resources, monitors and evaluates the Multisectoral HIV/AIDS response in the country.

The Ethiopian health care system is a three tier system with the assumption of specialized hospitals

serving more than one million people, district hospitals serving 500,000 people, primary health care

system with a health center serving 25,000 people and health post serving 5,000 people. The country

has been striving to address the primary health care principles of Almata declaration “health for all”

whereby more than 32,000 trained community health extension workers are providing the health

services at household level with full participation of the community (2).

With an estimated 790,000 HIV-infected people, HIV prevalence in Ethiopia was 1.5% in 2011. Of

the total number of people living with HIV in 2011, more than 380,000 were in need of antiretroviral

treatment and about 42,000 positive pregnant women needed drugs for prevention of mother to

child transmission (PMTCT). Ethiopia‟s HIV epidemic is heterogeneous among the population and

more prevalent among female population as compared to male population in the same age group. As

a result, females constitute 61% of the total people living with the virus (3). Furthermore, individuals

in the age group of 30-39 years are the most affected. Likewise, the epidemic exhibits geographic

variation. According to EDHS 2011 urban residents are more affected than rural residents (HIV

prevalence 4.2% in urban and 0.6% in rural). Gambella is the most affected region with 6.5%

prevalence followed by Addis Ababa (5.2%)(4).

In response to the epidemic, Ethiopia formulated the National HIV/AIDS policy in 1998. As a

commitment to implement the policy, the government had taken many steps including the

introduction of free ART service program in 2005 with strong support from partners.


Page 14

1.1.2 Overview of ART program in Ethiopia

In order to ensure ART for all in need at all levels, a number of major programmatic efforts have

been underway including the following:

ART Service Availability: Ethiopia rapidly scaled up ART services since 2005. The total number of

health facilities providing antiretroviral therapy has grown rapidly from 3 in 2005 to 838 as of June

2012. Of these, 818 (98%) are in the public sector and 20 (2%) are in the private sector. Among

these, 148 are hospitals and 690 are health centers (5).

Decentralization and task shifting strategies: After Road Map-I, which targeted to put 100,000 people

on ART between 2004 and 2006, the Road Map - II strategy targeted universal access to ART by

2010. To meet this target, the country has been scaling up comprehensive HIV prevention, care and

treatment through decentralization of service to health centers and through task shifting. In 2005

only physicians were allowed to prescribe ARV drugs. However, recognizing the shortage of

physicians in the country, the government employed a task shifting strategy. This is shifting the role

of ART drug prescription from the physicians to the middle health workers such as nurses and

health officers. In order to ensure service quality during task shifting, the country adopted a

mentoring program in most regions (6).

Policy and guideline development: The country issued the first ART guideline in 2003 and revised it

in 2005 to facilitate scale up of ART services. A stand-alone guideline for pediatric HIV/AIDS care

and treatment was issued in 2008 (7). In order to identify all people in need of treatment, the points

of entry for ART have involved self-referral, VCT or opt in model, provider initiated counseling and

testing (PICT) or opt out model, outpatient & inpatient clinical services, the community, NGOs, and

faith based organizations (FBOs), orphanages, antenatal care service, blood donors, social events

such as marriage and emigration and others.

Decision to start ART: ART eligibility is based on WHO clinical staging and immunological

assessment (CD4 count). In settings where there is no available or functional immunological

assessment, total lymphocyte count (TLC) has been used as a proxy (7). For patients in stage IV, the

guideline recommends to start the treatment irrespective of CD4 count.

All patients in stage III are eligible to start ART if their CD4 count is 350 cells/mm3 or below. If CD4

count is 200 cells/mm3 or less all patients are eligible for ART initiation irrespective of clinical

staging. In absence of CD4 count, all patients in stage III & IV are eligible for ART irrespective of

TLC. Patients in clinical stage II are eligible for ART initiation, if their TLC is 1,200 or less. However,

patients in WHO clinical stage I do not start ART based on TLC unless they are eligible with CD4

count (7).


Page 15

The 2008 guideline for pediatric HIV/AIDS care and treatment recommends assessment of children

on ART for opportunistic infections; physical growth and neurodevelopment need each month for

the first six months of treatment. In addition, hematologic, immunologic, liver and renal function

status assessment should be performed at time of enrollment or initiation of ART and then every six

months unless otherwise indicated. The immunologic criteria for starting ART in children are being

an infant, regardless of absolute CD4 count; < 750cells/mm3 for age 12-35 months; < 350cells/mm3

for age 36-59 months and < 200cells/mm3 for age 5 years and above (8).

Antiretroviral drug policy: The first national antiretroviral drug policy was developed in 2002 and the

first ART guideline for adolescents and adults developed in 2003. The guideline was revised in 2005

and again in 2007. WHO issued subsequent treatment guideline revisions in 2008 and 2010, but for

the time period during which this study was conducted, Ethiopia was utilizing the 2003 guideline

from 2005 to 2008 and the 2007 guideline from 2008 through the end of the follow-up period

(2011).

Patient monitoring: The country adopted and implemented the WHO 2006 patient monitoring

guideline in 2006. Parallel to the rapid ART scale up in the country, the ART patient monitoring

system was established to closely monitor and evaluate the ART patients and its program. More than

400 data clerks hired and trained on the patient monitoring tools. Training has been provided to

health workers on the same tool to increase the quality of the services and monitoring of the

patients. The paper based patient monitoring system established for ART patients has been a driving

force for the successful scale up of the ART program in the country (6)

Progress made: As of the end of 2012, Ethiopia had achieved ART coverage of 72% utilizing a CD4

count eligibility threshold for adults of 200 cells/µL. There was large discrepancy between coverage

for adults and children with adult coverage of 86% but only 20% coverage for children. From the first

introduction of free ART to June 2012, more than half a million people with HIV were enrolled in

chronic HIV follow up care, 379,190 people living with HIV had accessed free antiretroviral drugs,

and 274,708 (72%) were currently alive and taking their drugs (5)

1 .2 Ra t iona l e o f the s tudy

While the Government of Ethiopia has systematically monitored the number of people accessing

ART services, the effectiveness of these services have not been systematically evaluated. Although

there are some published local studies that assessed ART service outcomes, there is no nationally

representative study that assessed the five year ART patient survival rate in Ethiopia, as well as

impact of ART on immune function and quality of life. Thus, it is hoped that this study, utilizing a


Page 16

nationally representative sample, will fill this gap. In addition, this study will assess the level of ART

service implementation and identify gaps for policy and program implications.

1 .3 S tudy que s t ion s and ob je c t i ve s

1.3.1 Study questions

1. What is the ART patient survival rate in Ethiopia?

2. What is the status of quality of ART service implementation in Ethiopia?

3. What do communities perceive about ART and its impact in reducing mortality in

Ethiopia?

1.3.2 Study Objectives

General Objective: To assess the status of ART service implementation and patient treatment

outcomes in Ethiopia.

Specific Objectives:

1. To determine ART patient treatment outcomes in Ethiopia

2. To determine the pattern of ARV drug regimen and adherence in Ethiopia

3. To assess the status of quality of ART service implementation in Ethiopia

4. To assess the perception of the community towards ART and its impact in reducing

death because of AIDS in Ethiopia.


Page 17

CHAPTER – 2 : METHODOLOGY

2 .1 S tudy a r ea and per iod :

The study was conducted in Ethiopia nationwide, from October-December 2011. The detail study

area is described under the background section.

2 .2 S tudy Des i gn :

Mixed study designs involving cross-sectional and retrospective cohort studies were conducted by

employing both quantitative and qualitative data collection methods.

Retrospective cohort (follow up) study design was used to determine ART patient treatment

outcomes (objective 1) for a representative sample of adults and children initiated on ART between

September 2005 and May 2010 utilizing random selection from patient registers and medical

records. Patterns of ARV drug regimen and adherence (objective 2) were also determined from the

retrospective record review and supplemented by in-depth interviews of service providers and case

managers and client exit interviews.

Cross-section study design is also used to assess the status of ART service quality (objective 3). This

involved facility audits of human resources, facility characteristics (number of rooms, access to

running water, electricity, etc), equipment, and supplies by using an observation checklist. In addition,

we conducted key informants‟ in-depth interviews and client exit interviews to assess the process of

service delivery and client satisfaction. In-depth interviews were conducted with selected health

extension workers, religious leaders, and iddir leaders to assess the communities‟ perceptions.

2 .3 Popu l a t ion

2.3.1 Source Population:

The source population for the quantitative component of the study (record review) constituted all

medical records of HIV/AIDS patients initiated on anti-retroviral therapy at all health facilities in

Ethiopia between September 2005 and May 2010; for the exit interview all patients using ART

services during the time of the study in the country (October-December 2011). For qualitative data,

health professionals working on ART related services (health providers working in ART clinics,

laboratory, pharmacy, HIV expert patients and health extension workers) and community members

(religious and Iddir leaders) were considered as the source population.


Page 18

2.3.2 Study Population:

Health facilities: Facilities that have been providing ART for at least a year as of May 2010 are

included in the study.

Patients: Randomly selected ART medical records of patients ever enrolled in ART treatment

services from September 2005-May 2010 are included in the review.

For exit interview: Clients coming for ART treatment to the selected health facilities during the

time of data collection and systematically selected to be interviewed.

For in-depth interview: ART coordinators, case managers, health extension workers, community

members (Iddir and religious leaders), and expert patients were included in the study.

2 .4 I n c l u s i on and exc lu s ion c r i te r i a

2.4.1 Inclusion Criteria:`

Health Facilities: governmental, non-governmental, private or uniformed hospitals and health

centres that have been providing ART service for at least one year prior to the data

collection period.

Records for review: records of individuals diagnosed with HIV/AIDS, who were initiated on

ART at least one year prior to data collection.

Key informants for in-depth interview: Health workers with extensive experience working in

ART clinic, as approved by the head of the institution. Leaders of social and religious

institutions found in the study areas who have been working/living for at least five years in

the same locality.

2.4.2 Exclusion criteria:

Hospital facilities having < 200 patients ever started on ART (to maximize efficiency of data

collection).

Health centres having <100 patients who have ever started ART were excluded for same

reason (so as to get adequate records and be cost effective while moving to that site).

Health centres were selected from the selected hospitals‟ catchment areas. Priority was

given to those health centres with greater than 100 currently enrolled HIV positive patients.

Otherwise random selection was conducted to assure two selected health centres per

selected hospital.


Page 19

2 .5 . S amp l e S i ze de termina t i on and samp l in g techn ique s

2.5.1. Sample size determination:

For the quantitative record review: sample size was determined using STATA 10 CORP 2009

statistical software by using 5 years‟ patient survival as a primary outcome based on the following

assumptions. A 95% level of confidence (α=0.05) and power of 90% were considered. In addition, a

hazard ratio of 50%, lost to follow up proportion of 17%, death rate of 10%, and correlation of 95%

were considered. Moreover a design effect of 2 was considered as the multistage clustered sampling

technique was used. Based on these assumptions, the final sample for adult patients‟ (15 years and

older) records, who started ART from September 2005 to May 2010 were found to be 42,220. For

children (under 15 years), it was planned to include all the obtained records in the selected facilities.

Based on this, all 7,356 were reviewed. For the clients‟ exit interview: the sample size was

determined using STATA 10 CORP 2009 statistical software, with the assumption of 95% level of

confidence, anticipated proportion of client satisfaction to be 50%, margin of error of 5% and design

effect of 2. This provided a total of 2,094 participants.

Qualitative part: Key informants‟ interview: Sample of 30 randomly selected health facilities was

determined for the qualitative part. From each selected facility, one ART provider, one case

manager/expert patient and one ART coordinator, were interviewed in-depth. In addition, from the

surrounding community of the health facility, one health extension worker, one “iddir” leader, and

one religious leader were selected for in-depth interviews, resulting in 90 in-depth interviews of

community leaders and 90 in-depth interviews of key health facility staff.

2.5.2. Sampling techniques:

Multi-stage clustered sampling method was used to select study facilities and participants. To make

national representation, all health facilities providing ART services in all the nine regions and the two

city administrations were considered. As of May 2010, 148 hospitals and 410 health centers were

providing ART services in Ethiopia. As stated earlier, to maximize use of the data collection team,

hospitals with < 200 patients ever started on ART were excluded from the sampling frame. This

resulted in a pool of 120 hospital-based ART treatment facilities including facilities in all nine regions

and the two city administrations of Ethiopia. Hospital sites were clustered into groups by region/city

administration and patient load (≥3000 patients ever started on ART, 1000-2999, 500-999, 200-500).


Page 20

Half of the hospital sites from each cluster were selected for inclusion in the study, resulting in 62

hospital facilities.

For those hospitals with more than two health centers in its catchment area providing ART services,

two were randomly selected for inclusion in the study. Health centers that had been providing ART

for < 1 year as of May 2010 were excluded. One hundred twelve (112) health centers were

selected of a total of 410 health centers that were providing ART services, as of the time of data

collection. To achieve the required sample size, every fourth adult patient record (based on medical

record number recorded in the ART register) was reviewed. This resulted in 70% of patient

records coming from hospital facilities and 30% from health center facilities, reflecting the

distribution of treated patients countrywide. In instances in which patient records could not be

located, key information (including whether patient has continued follow-up, has died, or has been

lost, as well as CD4 information was abstracted from the ART register). In addition, we reviewed all

records of children who started on ART during the study time frame.

For the qualitative component of the study, we selected 30 health facilities and service providers and

community representatives from the catchment area for interview. For the exit interview, we

calculated sample based on the expected client load as 70% for hospitals and 30% for health centers.

2 .6 . Da ta co l l e c t i on proce s s

2.6.1. Measurements (Study Variables):

In this study the following baseline variables were assessed and monitored over 1-5 years.

Age at baseline, gender, baseline WHO stage, baseline functional status and subsequent functional

status, baseline CD4 count, subsequent CD4 counts, outcome (alive and on treatment, transferred

out, lost to follow-up, known dead).The variables to assess quality of the service include the

distribution of trained health professionals, availability of guidelines, availability of laboratory services,

availability of needed drugs, the perceptions of patients. Dependent or outcome variables: ART

patient treatment outcomes: one, two, three, four, and five year survival rates, immunologic and

functional status outcomes over years.

2.6.2. Data Collection Tools

Pre-tested structured questionnaires were used to review the patients‟ records; observation check

lists used for the facility audit; interview guides used to collect data related to the process of ART


Page 21

program provision; and community perceptions about ART and its impacts. Interviewer administered

semi-structured questionnaires were also used for the client exit interviews.

2.6.3. Pretest

All the instruments were pre tested in one health center in Addis Ababa prior to the actual data

collection, and necessary modifications were made based on the pre-test feedback. The pretest

involved looking at the completeness of the questions in addressing all the objectives, familiarity of

data collectors, as well as social and cultural acceptability of the questions.

2.6.4 Data Collectors and supervisors

Nurses and data clerks (diploma-level and above) with long experience in ART service provision

reviewed the medical records of ART patients. They were selected from all the regions by

competitive basis by considering their familiarity with the geography as well as local languages. The

principal investigators conducted the exit interviews and in-depth interviews and supervised the data

collectors.

2.6.5 Training of data Collectors:

Two days intensive training was conducted by the principal investigator for all data collectors,

which was followed by one day field pretest and again one day discussion of the pretest findings. The

training focused on the contents of the instruments, the objectives of the study, and the process of

accessing data both electronically and using hardcopies.

2.6.6 Data collection procedure

Twelve routes were established based on regions and main transportation road. Each team was

composed of three data collectors and one supervisor (PI). Two additional data collectors who avail

records and facilitate data collection process were included at each site/facility. At each health

facility, the team identified the sampling frame by identifying unique ART number of first patient

started on ART September, 2005 and that of the last patient started on ART through May, 2010.

The team selected patients from the record utilizing a systematic sampling method. Record reviews

were conducted in separate and private rooms.


Page 22

For the exit interview: case managers/expert patients accessed the clients through predetermined

interval based on daily load; they were interviewed in a separate and private room. For the facility

audit, the check lists were completed by inspecting the respective units and also asking someone

responsible in each unit as necessary. The key informant in-depth interviews among ART service

providers were conducted in private rooms after selecting the key informant in consultation with

the ART coordinator.

For the community representatives: key informants were selected in consultation with the

chairperson of the „kebeles‟ and health extension workers; and interviews were made after

appointing the selected informant by the HEWs. All the in-depth interviews were tape recorded

after taking consents in order not to miss important information.

2 .7 Da ta ana l y s i s

EPI-Info software was used for qualitative data entry; trained data encoders entered data at

FHAPCO office. STATA 10 software was used for data analysis. The distribution and characteristics

of the study population were determined by using frequency and percentage; descriptive statistics

such as mean, median and mode were also used to look at the patterns of parameters under study;

Cross tabulations also used to see the relation of variables to one another; trend analysis was done

to see the change in the immunological and biomarkers over the five years. Then, 6, 12, 24, 36, 48

and 60 month‟s survival analysis were determined. Kaplan-Meir was used to look at the relation of

each variable with multi-year survival; and Cox-proportional hazard was used to identify predictors

of five years survival. Tables and graphs are presented in the result section. The qualitative data was

transcribed verbatim in the field and analyzed centrally using thematic areas.

2 .8 Da ta qua l i t y con tro l

To ensure the quality of data, the study team pre-tested data collection tools. In addition, data

collectors and supervisors received intensive training. The supervisors checked each completed

questionnaire on daily basis.

2 .9 E th i ca l c l ea rance

FHAPCO obtained ethical approval from Ethiopia Health and Nutrition Research Institute (EHNRI)

Ethical Review Committee. Then, formal official letters were obtained from regional health bureaus

and submitted to health facility. Following this, permission was secured from the higher official of

each health facility before proceeding to data collection. Personnel working in the ART clinic

accessed the medical record review to ensure confidentiality. Data collectors reviewed the medical

records in private rooms and records were returned to their place daily. Prior to completion of

record abstraction, all collected records were kept in a locked cabinet.


Page 23

Furthermore, confidentiality was assured by omitting any individual or facility identifiers, and data

was analyzed in aggregate. A written signed consent was secured from all who participated in exit

interviews and in-depth interviews.

2 .10 Opera t i ona l de f i n i t i on o f te rms

Adherence to ART: the extent to which a patient strictly takes all ARV pills in the correctly

prescribed doses at the right times and right way observing the dietary restrictions.

Attrition Rate: the proportion of patients lost and dropped including death among those

who started ART.

Lost: A patient absent from health facility less than three months

Drop: patients who have not returned for follow-up more than three months after missing

their last scheduled visit or medication pickup.

Stop: discontinuation ARV medications while remaining in care.

Ever Started ART: Patients who started ART but may not still be taking ART (includes

currently on ART, dead, drop, lost or TO)

Currently on ART: Patients who are alive and on treatment at end of reporting period

Expert Patient: Trained HIV patient hired by health institutions providing ART services, who

provides psychological and social support ART patients to enhance initiation

Mortality: Reported number of documented deaths observed during ART from 2005

through the end of the follow up period.

Retention: refers to patients known to be alive and receiving ART at the end of a follow-up

period excluding transferred out from numerator and denominator

Transferred out: ART patients who are formally transferred to other health facility and have

had a transfer form completed by provider at the facility that the patient is transferring from.

Waiting Time: Time the patient spent in the facility to obtain the services, from availing

himself to the facility to leaving the compound.


Page 24

CHAPTER – I I I : RE SULTS

The results of the study are sub-structured based on the objectives of the study, as follows:.

- ART patients‟ treatment outcome from medical record review;

- ART patients‟ drug regimen pattern and adherence from medical record

- ART service quality from findings of facility observation, service providers‟ in-depth interviews,

and client exit interviews;

- Community perception about ART and its impact from in-depth interviews of community

representatives.

3 .1 ART Pa t i en t s ‟ Trea tmen t Outcome f rom Med ica l re cord rev iew

The ART patient medical record review findings assessed the following:

Background characteristics of ART patients at enrolment

ART patient treatment outcomes (survival, retention, death & lost , drop , and clinical and

immunological outcomes);

ART program performance at ART enrolment;

Predictors of patient survival and lost/drop

Patterns of ARV drug regimen and;

Adherence to care and treatment

The medical record review includes patients who had started ART from September 2005 to May

2010 and follow up duration is September 2011.

3.1.1Background characteristics of ART patients at enrollment

The medical record of patients includes a five years cohort of HIV patients, who started ART from

September 2005 to May, 2010. A total of 42,200 randomly selected adult patients‟ medical records

and records of 7,356 children less than 15 years old are included in this study. The median ages for


Page 25

adults and children at time of treatment initiation were 33 years and 8 years, respectively; and

among adults 56% were females. Of the total adult ART patients included in the study, 45.3% were

married, 32.8% divorced/widowed, and 15.8% never married, 6.5% missing data. Regarding their

education status, more than half (59.4%) attended either primary school or none at all, 25.9%

attended secondary school and only 7.4% attended tertiary education at the initiation of ART.

The majority (83%) of the study population were from urban residents. Among adult reviewed

records, 72% were taken from hospitals and 28% were from health centers (Table 1).

Table 1 Selected socio-demographic characteristics of HIV patients on ART at enrollment

Adult Children Adult & Children

Variables Percent N=42,220 Percent N=7,356 Percent N=49,576

Region

Tigray 9.4 3,970 11.3 829 9.7 4,799

Afar 1.0 426 1.1 79 1.0 505

Amhara 24.3 10,269 24.6 1,811 24.4 12,080

Oromia 21.6 9,132 17.7 1,304 21.1 10,436

Somali 1.6 677 0.4 27 1.4 704

Beni-gumuz 1.0 437 0.7 50 1.0 487

SNNP 9.1 3,831 6.3 462 8.7 4,293

Dire Dawa 2.1 881 2.2 163 2.1 1,044

Gambela 0.7 291 0.6 47 0.7 338

Harari 2.00 823 2.7 195 2.1 1,018

Addis Ababa 27.2 11,483 32.4 2,389 28.0 13,872

Residence

Urban 76.2 32164 77.0 5,642 76.3 37,806

Rural 16.4 6911 14.0 1,022 16 7,933

Missing 5.3 2245 9.0 692 7.7 3,837

Sex

Male 41.9 17,691 52.6 3,868 43.5 21,559

Female 57.8 24,400 46.7 3,438 56.2 27,838

Missing 0.3 129 0.7 50 0.4 179

Age

<5 yrs 39.8 2,930 39.8 2,930

5-14 yrs 58.8 4,323 58.8 4,323

15-24 yrs 9.5 4,041 9.5 4,041

25-34 yrs 43 18,163 43 18,163

35-49 yrs 37.6 15,908 37.6 15,908

50+ yrs 7.6 3,245 7.6 3,245

Missing 2 863 1.4 103 2.0 863

Median ages 33 for adult , 8 for children

Education

No education 26.6 11,250 26.6 11,250

Primary 32.8 13,851 32.8 13,851

Secondary 25.9 10,947 25.9 10,947

Tertiary 7.4 3,132 7.4 3,132

Not applicable (under 5) 0.2 76 0.2 76


Page 26

Missing 7.2 3,040 7.2 3,040


Page 27

Table 1 continued Adult Children Adult & Children

Percent N=42,220 Percent N=7,356 Percent N=49,576

Never married 15.8 6,690

Married 45.3 19,113

Divorced/ Separated 20.6 8,700

Widow 11.8 4,972

Missing 6.5 2,745

Specialized hospital 14.6 6,172 21.9 1,608 15.7 7,780

Regional referral

hospital

37.1 15,679 41.0 3,018 37.7 18,697

Zonal-district

hospital

20.5 8,667 20.6 1,519 20.5 10,186

Health center 27.7 11,694 16.5 1,211 26.0 12,905

Missing 0.0 8 0.02 8

Public 94.3 39,831 95.2 7,005 94.5 46,836

Uniformed 2.4 1,022 0.4 27 2.1 1,049

Private 2.5 1,035 0.7 50 2.2 1,085

NGO 0.8 325 3.7 272 1.2 597

Missing 0.02 7 0.03 2 0.02 9

Cohort

Year(September)

2005/6 18.8 7,939 9.2 680 17.4 8,628

2006/7 21.1 8,915 15.8 1,163 20.4 10,094

2007/8 19.1 8,066 18.6 1,371 19.1 9,456

2008/9 17.5 7,386 23.7 1,741 18.5 9,151

2009/10 15.6 6,570 21.1 1,549 16.4 8,140

2010/11 1.3 566 6.0 438 2.0 1,010

Missing 6.6 2,778 5.6 414 6.2 3,098

3.1.2 Biological and clinical characteristics of ART patients at enrollment

As is illustrated in Table 2 more than half (61.4%) of adult ART patients initiated ART while in a

working condition, 28% were ambulatory, and 5.9% of them were bed ridden. Close to 10% of

children initiating ART were identified as developmentally delayed at time of ART initiation, 60% at

regression stage, and 22% started ART at appropriate developmental stage. Majority (70%)of adult

and children ART patients initiated ART at WHO stage 3 or stage 4.

Of the 42,220 adult HIV patients records included in this review, 38,180(90%) had a baseline CD4

count. Of the total, 14,476 (34%), 14,964 (35%), 8,770 (21%) and 4,040 (10%) had CD4 counts of

≤100cells/mm3, 101-200cells/mm3, >200 cells/mm3, or had no CD4 counts recorded at the start of

ART, respectively. The mean CD4 + count of HIV patients at ART initiation was 171.5 (95%

confidence interval (169.3-173.6).


Page 28

Table 2 Biological and clinical characteristics of HIV patients at ART enrollment

Variables Adult Children Adult & Children

Percent N=42,220 Percent N=7,356 Percent N=49,567

Functional status

For Adult

Bedridden 5.9 2,474

Ambulatory 27.7 11,676

Working 61.4 25,919

Missing 5.1 2,151

For Children

Delay 9.7 714 6.4 3,188

Regression 60.1 4,419 32.5 16,095

Appropriate

developmental stage

22.1 1,626 55.6 27,545

Missing 8.1 597 5.5 2,748

WHO stage

Stage 1 8.0 3,362 10.0 737 8.3 4,099

Stage 2 16.8 7,091 23.0 1,692 17.7 8,783

Stage 3 56.8 23,965 51.3 3,770 55.9 27,735

Stage 4 14.4 6,090 12.0 884 14.1 6,974

Missing 4.1 1,712 3.7 273 4.0 1,985

CD4 category

CD4≤50 14.5 6,111 6.5 477 13.3 6,588

CD4: 51-100 19.8 8,365 6.7 494 17.9 8,859

CD4: 101-200 35.4 14,964 19.5 1,435 33.1 16,399

CD4: 201-350 18.5 7,793 22.6 1,664 19.1 9,457

CD4: >350 2.2 947 23.5 1,725 5.4 2,672

Missing 9.6 4,040 21.2 1,561 11.3 5,592

3.1.3 Survival and retention rate among HIV patients after initiation of ART

Survival

The clinical goal of ART program is to increase quality of life and prolong the life of HIV patients.

We have analysed survival rates for ART patients at 6, 12, 24, 36, 48, and 60 months. In the context

of this study survival refers the probability of living per 100 patient-years of treatment.

In this survival analysis, three scenarios were considered: best-case, midpoint and worst-case

scenarios. The best-case scenario assumed drop and lost to follow up patients are alive, the midpoint

scenario excluded transfer out, drop and lost from the analysis and the worst-case scenario assumed

drop is dead and lost is alive. At any given time the percentage of those in a given cohort who are

“lost” is very small; as soon as a patient misses an appointment, the facility‟s case manager initiates

attempts to retrieve the patient. Those who are successfully retrieved return promptly to the

“retained” category, while those who cannot be retrieved become “dropped” after three months.


Page 29

Using the worst case scenario the five years‟ survival rate for Ethiopia is 78%. The sharp decline

occurred in the first six months.

Figure 1 Survival rate of HIV patients who started ART from Sept. 2005- May 2010

Retention

Retention in this study means proportion of patients remaining in care and on ART drug regimen

after ART has been initiated. Estimated retention rates at 6, 12, 24, 36, 48, and 60 months were

calculated for the entire cohort and plotted. Transferred out patients have been excluded from both

the numerator and denominator in estimating the retention rates.

The total retention rate by duration of treatment is illustrated in figure 2. The retention rate among

HIV patients who started ART from Sept. 2005 to May 2010 is 77%. The 12 months and 60 months

retention rates for the entire cohort year of Sept. 2005-May 2010 are 82.4% and 72% respectively.

Most rapid period of decline occurs in the first six months. After six months, there is a continued

decline, but it is very gradual compared to first six months.


Page 30

Figure 2 Retention rates of HIV patients who started ART from Sept. 2005 - May 2010

Retention rate by cohort year

Figure 3 illustrates retention rate of HIV patients by start year of cohort and treatment duration.

Retention rate has significantly increased over the start year of cohort. For instance, the six months

retention rate has increased from 83.4% to 87.5% among the cohort of 2005/6 and 2009/10

respectively. And the total retention rate has also increased from 72.1% in 2005/6 to 81.5% in

2009/10. The five years retention rate among the cohort of 2005/6 is 72%.


Page 31

Figure 3 Retention rates of HIV patients by start year of cohort and treatment duration

Retention by age and sex

Twelve months retention rate is higher among children and female population. The 12 months

retention rate is higher (83.5%) among adult female compare to male (77.8%). Retention rate

between male and female children does not show any differences. However, significant difference is

observed in 12 month retention among adult and children with 81.2% retention rate among adults

and 90.2% among children (figure 4).


Page 32

Figure 4 Retention rate among HIV patients after 12 months of ART initiation by age and sex

Retention by regional distribution

Retention rate at 12 months after initiation of ART was calculated and plotted in Figure 5.Tigray

region has the highest (87.2%) 12 months retention rate followed by 85.4% for Harari & and SNNP

each. The lowest 12 month retention is recoded in Afar region (70.4%). Six regions (Oromia,

Benishangul Gumuz, Dire Dawa, Somali, Gambela, and Afar) fall below the national 12 month

retention rate of 82.4%.


Page 33

Figure 5 Retention rate for HIV patients by regional distribution for the cohort of

2005/6 – 2009/2010

Retention rate by residence and type of health facility

Figure 6 presents the entire retention rate by residence and type of health facilities. Retention is

higher (77.2%) at hospital level compared to health center (72%). Similarly, a difference was

observed in overall retention between urban (78.1%)and rural (74.8%).


Page 34

Figure 6 Retention rate for HIV patients by residence and type of health facilities for the cohort year

of 2005/6–2009/10

3.1.4 Attrition rate among ART clients

Table 3 illustrates the attrition rate of HIV patients after initiation of ART. Attrition rate includes

dead, lost, drop, and stop. The national average death rate is 9.3% and lost and drop together is

13.4%. Death accounted for 40% of the attrition rate while 60% is for lost/dropout rate. Attrition

rate above 30% was recorded in five regions: Afar (35%), Somali (34.3%), Diredawa (32.8%),

Benishangul gumuz (31.6%), and Gambela (31.1%).


Page 35

Table 3: Attrition among HIV patients after initiation of ART by region, 2005/6 – 2009/2010

Region

Median

follow up

months Dead Lost Dropped Stopped

Total

Attrition Retained N

Tigray 28.5 7.4 1.8 8.6 0.3 18.1 81.9 3,896

Afar 24.1 17.5 0.7 16.8 0.0 35.0 65.0 429

Amhara 31.6 12.8 1.2 7.3 0.2 21.4 78.6 10,321

Oromia 24.6 8.8 7.4 9.6 0.1 25.9 74.1 9,022

Somali 25.5 12.3 3.2 17.6 1.2 34.3 65.7 569

Beni-

gumuz

32.1

11.8 2.8 17.0 0.0 31.6 68.4 459

SNNP 35.7 9.1 2.7 8.5 0.2 20.4 79.6 4,208

Dire

Dawa

24.1

10.1 2.0 20.4 0.3 32.8 67.2 863

Gambela 30.0 8.4 1.5 21.3 0.0 31.1 68.9 334

Harari 26.5 8.8 3.3 8.0 0.0 20.2 79.8 784

Addis

Ababa

36.8

7.1 2.1 13.1 0.3 22.6 77.4 12,841

Total 30.5 9.3 3.0 10.4 0.2 23.0 77.0 43,726

Trend on death and lost/drop rate

Figure 7 illustrates a clear decline in 12 month mortality from 8.9% for the 2005/6 cohort to 5.8%

forthe2009/10 cohort. The greatest decline in 12 month mortality occurred between the 2007/8

and 2008/9 cohorts, while lost/dropout rate shows a sharp decline in the first year and has been

relatively constant at about 12% subsequently, as shown below.


Page 36

Figure 7 Proportion of death and lost/dropout rates by year of cohort, 2005/6 to 2009/10

Time of death and lost to follow up

This study revealed that majority (66%) of the deaths among ART users occurred in the first six

months of treatment. Similarly, half (50%) of the drop-outs from care did so during the first six

months of ART treatment (Figure 8).


Page 37

Figure 8: Time of death and lost to follow up among ART users among the cohort of 2005/6-2009/10

3.1.5 Immunological treatment outcome among ART patients

One of the ultimate goals of ART is to improve immunological responses (increase in CD4 count) of

the HIV patients after being on ART. Figure 9 presents the mean CD4 count at baseline, 12, 24, 36,

48, and 60 months and the absolute CD4 count changes among ART patients who have survived

during the course of treatment.

The mean CD4 count more than doubled from 145 to 328 for those who were retained in care for

the first twelve months of treatment. Thereafter, mean CD4 count response continued to increase

over subsequent 12 month periods for all patients retained in care. For the approximately 76% of

patients from the first three yearly cohorts retained in care at least three years, their mean 36

month CD4 count was 424. For the 75.5% of the first two cohorts retained in care for at least four

years, the mean 48 month CD4 count was 448; and for the 72.1% of patients from the first cohort

retained in care for at least 60 months, the mean 60 month CD4 count was 475. The overall gain

per year in absolute CD4 count was 66cells/µL.


Page 38

Figure 9 Mean CD4 + count among ART patients who are still alive and on treatment

3.1.6 Clinical and biological treatment outcome among ART patients

Functional status

In this study the clinical outcomes of ART patients were measured in terms of improvement in

functional status, weight gain, and reduction in anemia prevalence among those who are alive and on

treatment. Figure 10 illustrates the functional status of ART patients who are still alive and on

treatment. One third of the HIV patients initiated ART at ambulatory condition and after twelve

months being on treatment 54% were returned to working condition.


Page 39

Figure10 Functional status among ART patients who are still alive and on treatment

Weight

Figure 11 illustrates mean weight of adult male and female ART patients who are still alive and on

treatment. On average ART patients have gained 10% of their baseline weight which is 5-6Kgs at six

months and a slight increase in subsequent treatment durations.


Page 40

Figure 11: Mean weights of adult ART patients who are still alive and on treatment

Anemia prevalence

As figures 12 illustrates, almost half (49.3%) of men and 43% of women had anemia at enrollment.

The mean hemoglobin increased significantly in patients who received ART, but one fourth remained

anemic 12 months after ART initiation. For the purpose of this study we defined anemia for adults

Hgb< 13 mg/ml for male and < 12 mg/ml for female.


Page 41

Figure 12: Prevalence of anemia among adult ART patients who are still alive and on treatment

Figure 13: Prevalence of anemia among children < 15 year ART patients who are still alive and on treatment

3.1.7 ART program performance at ART enrollment

A key strategy for reducing HIV-related morbidity and mortality is to initiate ART as early as

possible before the virus has markedly impaired health. As assessed by baseline CD4 count, WHO

stage, and functional status, Ethiopia‟s ART program has demonstrated progress over time, as

depicted in Figure 14.


Page 42

Figure 14 Functional status, WHO staging and CD4 count at enrollment of HIV patients

3.1.8 Predictors of ART patients‟ survival and lost/drop

Predictors of ART patients‟ survival

By using the Kaplan-Meier survival curves, the existence of significance differences in ART patient survival

between sex categories, different levels of CD4 count, WHO staging, and functional status at enrollment

were tested and all of them were found to have statistically significant differences (p<0.05) on ART

patients survival. To determine the hazard ratio by controlling for confounders, Cox-proportional Hazard

model was applied. In this model, again all of them had statistically significant differences and were

predictors of survival on ART.

Patients who started ART at CD4 count above 200cells/mm3 were more likely to survive as

compared to those who started at CD4 count of ≤ 200cells/mm3. CD4 count of <50cells/mm3, 50-

100cells/mm3 and 101-200cells/mm3 at the start of ART had hazard ratios of 2.33 (95% CI: 2.03,

2.66), 1.58 (95% CI: 1.39, 1.81) and 1.31 (95% CI: 1.15, 1.50), respectively as compared to CD4

count of >200cells/mm3. Similarly, this study revealed that starting the drug at early stage of the


Page 43

diseases (at lower WHO staging) was associated with increased patient survival rate. This means the

higher the WHO stage at the start of ART, the higher the rate of mortality. Starting ART at WHO

stage-IV and Stage-III had the hazard ratio of 1.59 (1.28-1.95)and 1.56 (1.24-1.97)respectively as

compared to starting at stage I. Functional status at ART start was also found to have statistically

significant association with patients‟ survival. Starting ART at working functional status was found to

increase patients‟ survival significantly. In other words, starting the drug after being bed ridden and

ambulatory functional status had hazard ratio of 6.62 (5.82, 7.53) and 2.92 (2.65, 3.20), respectively,

as compared starting at working functional status. Sex of the ART users was also found to have

statistically significant effect. Being male had a hazard ratio of 1.34 (1.24, 1.46) compared to female

(table 4).

Figure 18: Kaplan-Meier survival curve by WHO


Page 44

0.0

00

.25

0.5

00

.75

1.0

0

0 6 12 24 36 48 60

Month since start of ART

Male Female

Kaplan-Meier survival estimates

0.0

00

.25

0.5

00

.75

1.0

00 6 12 24 36 48 60

Months since start of ART

Working

Bedridden

Ambulatory

Kaplan-Meier survival estimates by funcational status at enrollment

0.0

00

.25

0.5

00

.75

1.0

0

0 6 12 24 36 48 60

Months since ART started

< 50

50-100

100-200

> 200

Kaplan-Meier survival estimates by CD4 at enrollment

0.0

00

.25

0.5

00

.75

1.0

0

0 6 12 24 36 48 60

Months since start of ART

Stage 4

Stage 3

Stage 2

Stage 1

Kaplan-Meier survival estimates by WHO staging at enrollment

Figure 15 Survival between female & male Figure 16 Survival by functional status

Figure 17 Survival by CD4 + count Figure 18 Survival by WHO staging


Page 45

Table 4. Hazard Ratio (HR) of Cox Proportional Hazards model and 95% CI interval in the

estimation of the risk of death according to selected characteristics of patients at enrollment

(age 15+)

CD4 category Hazard Ratio [95% Conf.]

CD4: 200+ 1.00

CD4: 101-200 1.31 (1.15-1.50)

CD4: 51-100 1.58 (1.39-1.81)

CD4: <=50 2.33 (2.03-2.66)

WHO stage

Stage 1 1.00

Stage 2 1.11(0.87-1.39)

Stage 3 1.59(1.28-1.95)

Stage 4 1.56(1.24-1.97)

Functional status

Working 1.00

Ambulatory 2.92(2.65-3.2)

Bedridden 6.62(5.82-7.53)

Age

15-24 yrs 1.00

25-34 yrs 0.84(0.72-0.97)

35-49 yrs 0.81(0.70-0.95)

50+ yrs 1.08(0.90-1.29)

Sex

Female 1.00

Male 1.34(1.24-1.46)

Type of facility

Specialized hospital 1.00

Regional referral hospital 1.04(0.91-1.19)

Zonal-district hospital 1.18(1.02-1.37)

Health center 2.09(1.83-2.40)

Residence

Urban 1.00

Rural 1.09(0.98-1.21)


Page 46

Table5. Hazard Ratio (HR) of Cox Proportional Hazards model and 95% CI interval in the estimation

of the risk of death according to selected characteristics of patients at enrollment among children

age 0-14 years

Variables Haz. Ratio [95% Conf.]

WHO stage at start of ART

Stage 1 1

Stage 2 0.91 (0.49-1.68)

Stage 3 1.38 (0.80-2.38)

Stage 4 2.49(1.39-4.47)

Functional status at start of ART

Appropriate dev. stag 1

Regression 1.54(1.01-2.34)

Delay 4.66(2.90-7.49)

Age at start of ART

<1 year 1

1-4 years 0.85(0.52-1.39)

5-14 years 0.65(0.40-1.04)

Sex

Female 1

Male 0.91(0.69-1.19)

Type of facility

Specialized hospital 1

Regional referral hospital 1.58(1.09-2.29)

Zonal-district hospital 1.42(0.9-2.2)

Health center 1.59(1.00-2.52)

Residence

Urban 1

Rural 1.01(0.68-1.48)


Page 47

Predictors of lost/drop

Table 6 Hazard Ratio (HR) of Cox Proportional Hazards model and 95% CI interval in the

estimation of the risk of lost to follow up (lost, dead or stopped) according to selected

characteristics of patients at enrollment (adults 15+)

Variables Hazard Ratio (95% CI)

Age

15-24 yrs 1.93(1.65-2.25)

25-34 yrs 1.32(1.16-1.51)

35-49 yrs 1.05(0.92-1.20)

50+ yrs 1.00

Sex

Male 1.46(1.37-1.57)

Female 1.00

Type of health facility

specialized hospital 1.00

regional referral hospital 0.96(0.87-1.05)

zonal-district hospital 0.87(0.78-0.97)

health center 1.03(0.93-1.14)

Residence

Urban 0.87(0.79-0.94)

Rural 1.00

Education

No education 1.37(1.20-1.56)

Primary 1.24(1.09-1.41)

Secondary 1.05(0.92-1.19)

Tertiary 1.00

HIV status disclosure

Yes 0.95(0.88-1.02)

No 1.00

Functional status

Bedridden 2.46(2.19-2.77)

Ambulatory 1.49(1.39-1.60)

Working 1.00

Marital status

Married 1.00

Never married 1.38(1.27-1.51)

Divorced/separated 1.29(1.19-1.41)

Widow 1.09(0.98-1.22)


Page 48

3 .2 ART Pa t i en t s ‟ Drug Reg imen Pa t te rn and Adherence

(med ic a l r ecords )

3.2.1 First and second line ARV drug regimen use

According to the revised 2007 guideline of antiretroviral drugs in Ethiopia, the appropriate combined

drug regimens used for first line ART in the study period were Stavudine (d4T) or Zidovudine (AZT)

with Lamivudine (3TC) and Nevirapine (NVP) or Efavirenz (EFV). Figure 19 illustrates the

distribution and type of drug regimens among ART patients.

For ART patients with 60 months of follow up and still on ART the most frequently used ARV

regimen was AZT+3TC+NVP (25%) and d4T+3TC+NVP (25%), and AZT+3TC+EFV (14%).In this

study we have observed slow (2%) regimen-switch rate among ART patients from first line to 2nd

line after five years on treatment.

Figure 19: Patterns of ART drug regimens among ART users who are still alive and on drug after 60 months

start of ART


Page 49

3.2.2 ART drug regimen change

Figure 20 illustrates number of ART patients changing drug regimen & proportion with toxicity as

the reason for change by duration of treatment. Thirty percent of the drug regimen change occurred

in the first six months following ART initiation. Toxicity and side effects accounted for 60% of the

reasons for regimen changes during the course of treatment. The development of new TB (20%) in

the first six months of treatment is cited as the second most common reason for change of

treatment. For patients with 60 months of follow up the most commonly cited reason is again

toxicity but not the development of new TB.

Figure 20 Patterns of drug regimen change and proportion of patients who developed toxicity


Page 50

3.2.3 Adherence to care and treatment

Adherence to care and treatment was measured in relation to appointment keeping, drug picking

behaviour, and taking pills.

Appointment keeping and drug picking behavior

Adherence regarding appointment keeping in this study is defined as presenting for an appointment

within seven days of scheduled appointment date. Among ART patients, 89% met this appointment

keeping adherence standard. However, this figure was lower (82%) among those who subsequently

were lost or died. In Ethiopia ART patients are expected to pick up their drugs every month before

completing their previously prescribed supply. Among patients who are still alive and on treatment,

98% pick up their drugs on time.

Figure 21.Clinic appoint keeping among ART patients alive and on ART, and among those who

subsequently were lost to follow or died


Page 51

Adherence to treatment: self-reported pill count:

Ideally, pill counts should be used to measure adherence to treatment. However, such practice is

not common in the country. Instead, health providers ask patients to report on their missing doses

and they categorize as good if patient self-reports having missed ≤ 3 doses in the prior month; fair if

4-8 doses were missed; and poor if >8 doses were missed. Based on these self-reports, 98.5% of

active ART patients are considered as having good adherence.

Figure 18 depicts comparison of Ethiopia with globally suggested targets on early warning indicators.

To this end, the lost/drop status, appointment keeping, on time ARV drug pick up, and retention on

1st line drug regimen were within the globally suggested targets.

Figure 22 Early warning indicators in Ethiopia (2005/6-2010/11) and globally suggested targets


Page 52

The qualitative study indicated that there is a high level of knowledge about the importance of ART

and adherence. It is observed from the qualitative study that the existence of case managers, expert

patients & HEWs greatly contributed to improving ART patients‟ adherence. However, there still are

patients not adhering to their drugs. Common reasons for non-adherence include: stigma &

discrimination (perceived or real), low socio-economic status (unable to pay for food/nutrition,

transportation, laboratory services and OI drug costs), spiritual reasons, forgetting appointment,

drug side effects, long waiting time, and substance use (alcohol and chat).

In addition, there are some challenges to maintain adherence. These include: wrong address for

defaulter tracing, turnover of peer educators due to their receiving no regular salary, unavailability of

funds to pay for fixed phone line and mobile card, difficulty in counseling individuals with hearing

problems, mental impairment, and little opportunity for PLHIV to participate in meetings and be

involved in decision making.

3 .3 ART Ser v i c e Qua l i t y i n E th iop i a

This section presents the results relevant to (Objectives 3) of this study and covers findings from

facility observation, service providers‟ in-depth interviews, and client exit interviews;

3.3.1 Findings from facility observation

A total of 80 health facilities (40 hospitals and 40 health centers) were observed to assess the quality

of ART service in relation to the availability of necessary guidelines, facilities and services in ART

clinic, pharmacy and laboratory units. Of the observed health facilities, 90% were public owned and

10% were uniformed, private and NGO owned (Annex 2: Table B)

Availability of ART and related guidelines: ART guideline was not available in 22% of the observed

facilities and in another 27% was reported as available, but was not observed either on the table or

in the shelves and boxes of the units. National PEP guideline and ART implementation guideline were

not available at 50% and 45% of the observed facilities, respectively. Adherence counseling protocol

was not available at68% of the observed facilities. Similar problems were observed for guidelines

necessary for laboratory procedures (Annex 2: Table C).

Examination room: Among the health facilities observed, 26%, 25% and 26% did not have auditory

privacy, visual privacy, respectively. Unavailability of running water (43%), hand washing soap (43%)

and mixed decontamination solutions (47%) were also observed in a significant proportion of the

observed facilities (Annex 2: Table D).

Laboratory services: Nearly nine- in- ten of the observed facilities have necessary laboratory

equipment: functional refrigerator (87%), microscope (94%) and centrifuge (92%) in their lab unit.

CBC, renal function test, liver function test and hepatitis B virus test were not performed in 40%,


Page 53

49%, 50% and 49% respectively during the time of data collection. Furthermore, unavailability of

disinfectants, disposable non-latex gloves, single use hand drying towels were among the problems

observed in the laboratory units of the observed facilities (Annex 2: Table E). CD4 cell count test

has been determined for patients before start of ART nearly in all of the facilities. Among visited

health facilities, 46% were equipped to perform CD4 count tests, 53% send samples to nearby health

facilities, and less than 2% had no access to CD4 testing facilities. Regarding immunological

monitoring, 82% of the health facilities perform CD4 count test every 6 months during follow up

visits (Annex 2: Table E).

Pharmacy services: More than 2/3 of the observed facilities have stand-alone ART pharmacy and

around half (49%) received ART drug supply in the last four weeks (Annex 2: Table F).

Health Human Resources: Ethiopia has incorporated a strategy of task shifting in recognition of the

general shortage of physicians in the country. Of the sites visited, 42% had no MDs on staff (this was

the case at all health centers and while there were doctors on the staff of all hospitals, 22% of visited

hospital-based ART clinics had no medical doctors staffing the ART clinic.” More than 95% of the

facilities have data clerks and case managers. (Annex 2, Table G)

3.3.2 Findings of ART clients exit interview

The exit interview tried to assess the quality of the process of ART service delivery from clients‟

perspective and their satisfaction.

Background characteristics of the exit interview respondents: Exit interviews were conducted

among randomly selected 1,216 ART users. Nearly all, 1,205 (99%) of the clients were from public

health facilities and more than half (59%) were females. The mean age of the respondents was 35.0

(±9.2) years. Slightly more than half (52%) were married. Orthodox Christian 859(71.3%) was the

leading religion and most, 981(81.3%), were urban residents. The median monthly income of the

respondents was 400 ETB (Annex 3, Table H).

Access to ART services: Majority, 845(76.6%), reported that ART facility was available within 10 km

of their residential home. Similar proportions use the services by moving on foot (48.5%) and by

vehicle (51.5%). Some proportion 196(16.5%) had started the ART in another facility and came to

the current facility. However, 49(25.0%) came without any referral notice. Job (35.0%) and not being

satisfied with the services (30.0%) of the previous facility were the main reasons for coming without

referral notice (Annex 3: Table I).

Client Provider Interaction: More than three-quarters, 946(78.3%), reported that the service

providers explain the side effects of HIV medications most of the time or all of the time. About four-

fifth, 981(81.2%) reported that their provider helps them remember their medications most or all

the time. Respondents reported that their HIV care provider most or all of the time explained the


Page 54

medical tests to be given (73.9%), how to stay healthy (82.8%), and how to avoid transmitting the

virus to others (79.1%).

Clients‟ Satisfaction: Majority of the respondents, 1079(89.1), 1078(88.9), 960(79.5), 1099(91.0),

910(75.1), 1094(91.1%) and 918(76.0%) reported that they were satisfied with the reception, physical

examination, laboratory services, pharmacy service, waiting time, privacy and facility distance,

respectively (Annex 3: Table J). The majority, 1,035 (66.1%), rated the overall quality of the ART

service as good and above; and 1,020(87.6%) agreed that they recommended the ART service in the

same facility in case they found someone in need. Similarly, most of the respondents, 1,123(93.6%),

agreed that the stand alone (separate) ART clinic is more comfortable for the users as opposed to

the integrated one. This is mainly because they get better or more efficient services in the stand

alone clinic (Annex 3: Table K).In order to identify additional problems related to the quality of

ART service and clients‟ suggestion, open ended questions were asked. Majority of the respondents

mentioned long waiting time, particularly recently. The main reasons raised for this were difficulty in

getting cards as they were mixed with other cards (HMIS), card loss, and limited number of service

providers as compared to client load. Leaving of trained staff (staff turnover) and non-punctuality of

available staff were also among the mentioned reasons.

The other major problem raised was related to laboratory and OI drugs. Most of the respondents

reported that all labs and OI drugs were free and available some time ago. But now most of them

are fee based and sometimes not available, and they were forced to go out to a private clinic for

some lab tests and OI drugs. Unavailability of CD4 count machine, delay or not getting CD4 count

results were also mentioned. As solutions, majority suggested separate clinic that is able to handle

ART cards separately, additional trained health workers, some financial support for the poor or

making all the lab and medications (including OI drugs) free, and increasing the period of the drug

offer from monthly base so as to reduce frequency of coming to the clinic.

3 .4 Commun i ty Pe rcep t i on abou t ART and i t s Impac t s

3.4.1 Perception about HIV/AIDS burden

Majority of the respondents perceived that the burden of HIV/AIDS has been decreasing; few

perceived it as either stabilized or increasing. Similarly, great majority perceived that HIV/AIDS is still

a major health problem even though it has been decreasing. Almost all respondents perceived that

there was either a reduction or great reduction in the pattern of death due to HIV/AIDS after

introduction of ART.


Page 55

3.4.2 Perception about care and support

Great majority of the respondents perceived that there was no treatment option for AIDS other

than ART; few reported ART plus holy water and/or prayer. The commonly reported available

support systems available for PLHIV were: Iddir; PLHIV association and/or network of PLHIV, OSSA,

Red Cross, community volunteers, Mum-to-Mum support group, governmental and/or non-

governmental organizations, religious organizations, and community development associations.

3.4.3 Perception about ART access and use

Most of the respondents had the view that the community‟s perception about ART has been

improving over time. “ART improves wellbeing and is not a cure for HIV”; and “ART inhibits

replication of the virus” were among the commonly reported benefits of ART. Respondents believed

that access to ART services are not a problem in most cases except for few cases from rural areas.

However, some case managers reported that some patients especially employees and merchants

come from far distances because they do not want to take ART from health facilities around their

usual residential area. Almost all respondents reported that the usage of ART and the pattern of use

showed improvement compared to earlier years. A few community members reported that some

patients still either do not take their ART openly or do not use at all due to fear of stigma and

discrimination.

Concerning open discussion about ART, mixed responses were observed; some reported that many

patients discuss openly while few do not tell even to their partners and use ART secretly. Some

others reported that open discussion commonly happened among ART users and patients in PLHIV

association and some patients didn‟t inform even their partner. Still some others reported that many

people do not want to talk about the issue openly because of fear of stigma and discrimination and

only those who need support discuss the issue openly while others who were economically capable

kept it secret. The commonly reported problems faced by ART users were: drug side-effects, stigma

and discrimination (perceived and real), lack of nutritional support, financial problem, transportation

expenses etc.

3.4.4 Perception about effects of ART


Page 56

Nearly all of the respondents stood in favor of positive effects of ART on morbidity and mortality.

The following are some of their expressions; “beds are not occupied,” “burial not common,” “death

and disease decreased,” “huge reduction in mortality,” “dramatically decreased,” “Great reduction,”

“clearly decreased,” “huge change,” “visible decrease,” etc.--all stressing the positive impact following

ART use. Similarly, the majority of the respondents indicated the positive social and economic

impact of ART by the following expressions: “increased workforce,” “improved health and

wellbeing,” “living long and support their family,” “decreased stigma and discrimination,” “great

improvement in life quality,” “enable many families to grow their children and leading their family

smoothly,” “helped people to participate in any social relation freely,” “helped in reducing orphans

and dependents,” “enhanced openness,” “improved wellbeing and decreased dependency.”

Respondents were also asked to suggest how to improve ART services in the future and the

following were forwarded: create jobs for PLHIV; increase fund; increasing education in media;

involving community organizations; working with community; improve human resource training and

making trained human resource active; increasing test uptake and expanding to rural area; special

mechanism for sex workers and street girls; appropriate use of funds; income generation activities

for PLHIV; special emphasis for young females; working with Idir and PLHIV, local community,

religious leaders; increasing ART sites, expanding to rural sites; free opportunistic infection

treatment; maintain the current effort were among the recommendations forwarded by participants

to improve future ART services.


Page 57

CHAPTER IV PROGR AM IMP L I CAT IONS

4 . 1 P ro g ram im p l i c a t i on

Treatment outcome of ART patients improved

The ultimate goal of ART is to improve quality of life and postpone death among HIV

patients. To this end, among the study population, 10% weight gained after six months of

ART start, increment in haemoglobin level and reduction in anaemia prevalence have been

observed. Immunologically, HIV patients have doubled their baseline CD4 count after six

months of treatment. More than doubled in the first six months and continued to rise over

the subsequent 4 + years is encouraging.

The five years survival rate for Ethiopia is found to be 78% (based on the worst case

scenario).

Retention rate improved over years:12 months retention rate after initiation of ART is

82.4%. Improvement in 12 months retention rate has been observed over the last five years;

from 80% in 2005/6 to 83.4% in 2009/2010. Retention rate is highest (87%) in Tigray and

lowest (70%) in Afar region. Furthermore, better retention rates are observed among

children< 15 years and among adult females compared to adult males.

Lost to follow up and death rate reduced

Drop out from treatment after initiation of ART is one of the challenges of an ART program. In

Ethiopia, lost, drop out and death rate (attrition rates) have been significantly reduced over the

last five years. However, Afar, Diredawa, Benishangul Gumuz, Gambela, and Oromia region

continue to have attrition rates above 30%.

Adherence to care and treatment improved

Recently ART patients‟ adherence to treatment and care has significantly improved. The

introduction of expert patients, case managers, health extension workers, and strong adherence


Page 58

counselling has greatly contributed in the improvement of adherence among ART patients.

However, stigma and discrimination remain reasons for not adhering.

Treatment initiation at enrollment improved

Several studies have shown the direct relationship between early intervention of ART and

treatment effectiveness. In this study we have observed that especially in the early years of

access to free ART, treatment initiation occurred late, as assessed by functional class, WHO

stage, and baseline CD4.

However, with each successive year, treatment is being initiated earlier as indicated by all three

of these measures. This is an encouraging trend and needs to be maintained in order to reduce

AIDS related mortality and improve HIV patient‟s quality of life.

Slow drug switch from 1stline regimen to 2ndline regimen was observed

Slow drug switch (only 2%) from 1st line to 2nd line regimen observed among ART patients who

are still alive and on treatment after 60 months of initiating ART. This is very low compare to

the duration of the ART program in the country. This might not reflect the true migration from

first line to 2nd line drug regimen because of the weak clinical and immunological treatment

failure identification. Hence, it needs further investigation in order to see the true drug switching

pattern in the country.

Given the observations regarding quality of ART service implementation noted in this study,

supportive supervision should be strengthened to assure that key guidelines are available at all

service locations and problems with lost or misplaced patient cards are corrected through

improved card handling practices. Additionally, steps must be taken to assure that laboratory

tests needed for appropriate safety monitoring and treatment effectiveness monitoring are

available either on site or through efficient sample transport mechanisms, and that laboratory

equipment is maintained and repaired in a timely fashion.” (or something to this effect).

Positive Community perception about ART and its impacts observed

Given that in this study the majority of community representatives expressed an understanding

that ART has improved the quality of life and reduced mortality from HIV, we may expect that

fear, which is the root cause of stigma and discrimination, may be lessening, and that support

rather than rejection by the community may be forthcoming.

4 . 2 S t ren g th s and l im i t a t i on s o f t he s t ud y

4.2.1 Strengths of the study

Design mix: This study used both follow-up (retrospective and cohort) and cross-sectional

study designs which helped in complementing one another and assessing the ART services

from different dimensions (input, process, output and outcome).


Page 59

Method mix: the study used different data collection methods involving both quantitative and

qualitative methods. These include record review, in-depth interview, and client exit interview

which enabled the authors to look at the quality of the services from perspectives of the

service users, providers, and the community.

The study monitored treatment outcomes over a long period: This study assessed the

outcomes of ART initiated over a five year period from 2005 until 2010, enabling survival

trends to be identified and serving as a historical account against which future treatment

achievements and challenges can be measured,

Large sample size and nationwide sample frame: this study used large sample size (42,220

adults plus 7,356 children) and involved all the nine regions and the two city administrations,

assuring that the findings were representative of the entire country‟s treatment performance.

Professional mix: the principal investigators were drawn from different professions and

backgrounds, experiences and service areas. i.e. The mix of the researchers including

academicians, program owners and implementers, clinicians, epidemiologists, reproductive

health professionals, statisticians and others, ensuring the quality of the research methodology

and content.

4.2.2 Limitations of the study

It was planned to observe all the health facilities (62 hospitals and 112 health centres). However,

observation was made for 40 hospitals (64.5%) and 40 health centres (38.5%). This might be due

to the fact that in some remote (rural) health centres only one or two health workers were

available and the observation checklist was not completed. This might have underestimated the

problems related to quality of ART services in more remote service areas.

Similarly, health facilities with low caseloads were excluded from the study. These sites where

providers have limited experience may have lower quality of care and poorer survival and

retention rates. The study was unable to assess whether that is the case. During the period of

2005-2007, ART service was availed mainly in big hospitals. With the policy of ART service

decentralization and task shifting, many ART patients have been transferred out to another

health facility. As a result they were excluded from this study because it was not possible to

follow the course of ART in these patients. This might have affected the estimates of survival. So

it is important to take these limitations into consideration when interpreting and using the

findings of this study.


Page 60

CHAPTER V : CONCLUS IONS &RECOMMENDATIONS

5 .1 Conc lu s i on s

From the first introduction of free ART in Ethiopia in 2005 through June 2012, more than 379,000

people living with HIV were started on antiretroviral therapy. This study identified a representative

sample of 42,220 adults and 7,356 children initiated on treatment between September 2005 and May

2010 and determined their outcomes as of October-December 2011. Of the patients enrolled on

treatment in 2005/06, the five year survival rate was 78%. For each yearly cohort initiated on

treatment since then, the one, two, three, and four year survival rates have progressively improved.

Earlier initiation of treatment as assessed by CD4 count, WHO clinical staging, and functional status,

was associated with improved survival. Among survivors, mean CD4 counts more than doubled

over the first six months of treatment, and continued to rise thereafter annually over the course of

follow-up. Clinical indicators that should be reflected in quality of life also improved significantly.

These included weight gain and reduction in prevalence of anemia. Though the overall attrition rate

in this study was 23.4%, significant improvement in patient retention rate has been achieved in the

last five years.

These accomplishments have been achieved despite the presence of some significant resource and

service delivery gaps identified in this study including limited number of highly trained health

professionals, inadequate facilities for confidential and safe patient care, inconsistent access to

treatment guidelines and other key job aids, problems with storage of patient records leading to

misplaced and lost records and long waiting times, and inconsistent access to critical laboratory

studies. Slow drug regimen switch from 1st line to 2nd line was observed, and may suggest failure to

detect treatment failure. Despite these resource and service gaps, ART drug adherence, as measured

in this study was high; and client satisfaction pertaining to counseling, information provision,

maintenance of confidentiality all received high marks. Moreover, almost all of the community

perceived that ART has brought significant effect in reducing the burden of the disease in the form of

preventing morbidity and mortality and improving the quality of life of PLHIV.


Page 61

5 .2 Recommenda t ion s

Based on the findings of the study the investigators forwarded the following recommendations to the

concerned bodies:

a) Policy level

The Federal Ministry of Health or anybody working at the policy level has to:

Establish better mechanism for clinical, immunological, and virological monitoring of ART

patients

Avail ART and ART related guidelines, implementing manuals, job aids, standard operating

procedures, and monitoring tools at all health facilities providing ART

Strengthen the sample transfer mechanism and increase performance of viral load tests so

that the existing high capacity of viral load machines is optimally utilized in the country in

order to detect treatment failure early

Standardize measurement unit for reporting laboratory tests

b) Program level:

Establishing mechanism for the maintenance and replacement of CD4 machines

Formulating better strategy of measuring adherence to treatment other than self-report

Conducting further investigation on the reason for slow regimen shift from 1stline to 2ndline.

Maintaining and strengthening the current stand-alone ART clinics

c) Facility level:

Facilities should perform key required laboratory tests including: Hb, liver & kidney function

tests for all ART patients at baseline and as recommended in current treatment guidelines

Encourage health providers to identify patients with suspected treatment failure as

determined clinically and immunologically, and report periodically

Engage clinical mentors in the identification of treatment failure and drug switch to know the

true picture of 1st line to second line regimen migration

Health workers training needs to emphasis HIV and confidentiality

Strengthen adherence counselling particularly among young 15-24 years and male population

Improve the current ART patient card handling system to avoid long waiting time and loss of

patients‟ cards

Develop and implement Quality Control Tools for facilities to monitor the quality of

services they are providing


Page 62

d) Community level

Strongly address stigma and discrimination at different levels through open discussion,

community conversations and mobilizations

Educate the larger community on the impact of stigma & discrimination on HIV patients and

how it affects their adherence

Train community counsellor ( with local language)

Create a better mechanism of nutritional support for needy ART patients


Page 63

ANNEXES :

Annex 1 Re co rd re v i ew amo ng ART p a t i e n t s

Table A. Distribution of record review data among ART clients according to non-missing cases

Variables % with non-missing,

(n=49,576)

Address

Region 99.8

Type of facility 99.8

Facility owner 99.8

Demographic variables

Sex 99.5

Age at start of ART 93.1

Education 88.5

Marital status 85.9

Duration

Date HIV confirmed 93.6

Valid start and end date 94.2

Date start of ART 98.5

End date 98.5

Patient Outcome 97.7

Clinical result at baseline

Weight 96.4

Height 12.8

WHO disease stage at start of ART 95.8

Functional status at start of ART 94.3

Laboratory tests

CD4 count at start of ART 88.6

Hemoglobin 76.0

SGPT 62.0

SGOT 52.0

BUN 25.0

Creatinine 21.0

Annex I I : Hea l t h f a c i l i t y ob serva t i ona l check l i s t Table B: Characteristics of the Health Facilities observed to assess the quality of ART service, December 2011,

Ethiopia.

Variable Freq. Percent

Region

Tigray (1) 13 16.2

Amhara (3) 14 17.5

Oromiya (4) 20 25.0

Somali (5) 2 2.5

B/Gumuz (6) 2 2.5


Page 64


SNNPR (7) 19 23.8

Dire Dawa (9) 4 5.0

Gambella (12) 3 3.8

Harai (13) 3 3.8

Total 80 100.0

Type of facility

Specialized Hospital 12 15.0

Regional Referral Hospital 6 7.5

Zonal/District Hospital 22 27.5

Health Centre 40 50.0

Total 80 100.0

Facility ownership

Public 72 90.0

Uniformed 2 2.5

Private 4 5.0

NGO 2 2.5

Total 80 100.0

Does TLC done before ART start?

Yes, in this facility 25 32.9

Yes, but blood sent else where 14 18.4

Yes, but client goes elsewhere 6 7.9

Not done at all 31 40.8

Total 76 100.0

Frequency of TLC test for follow up

Only if indicated by pt. condition 28 62.2

Every 6 months 15 33.3

Other 2 4.4

Total 45 100.0

Does CD4 count done before ART start?

Yes, in this facility 35 45.5

Yes, but blood sent else where 32 41.6

Yes, but client goes elsewhere 9 11.7

Not done at all 1 1.3

Total 77 100.0


Page 65


Frequency of CD4 count determination

Only if indicated by pt. condition 11 15.1

Every 6 months 60 82.2

Other 2 2.7

Total 73 100.0

Table C: Availability of guidelines in the observed ART units and laboratory units, December 2011, Ethiopia

Guidelines and protocols

Guidelines Observed

n (%)

Reported, but not

seen

n(%)

Not available

n(%)

Total

n(%)

National ART guideline 40(51.3) 21(26.9) 17(21.8) 78(100.0)

National PEP guideline 26(32.9) 14(17.7) 39(49.4) 79(100.0)

Pediatrics HIV/AIDS care & Rx

guideline

45(57.7) 17(21.8) 16(20.5) 78(100.0)

ART program implementation

guideline

30(39.5) 12(15.8) 34(44.7) 76(100.0)

Adolescents & adults OIs & ART

management guideline

34(43.6) 16(20.5) 28(35.9) 78(100.0)

Adherence counseling protocol 10(13.0) 15(19.5) 52(67.5) 77(100.0)

PMTCT guideline 39(50.6) 12(15.6) 26(33.8) 77(100.0)

Lab. safety protocols 22(30.1) 15(20.5) 36(49.3) 73(100.0)

Infection prevention guideline 19(25.3) 21(28.0) 35(46.7) 75(100.0)

Blood safety guideline 16(22.5) 10(14.1) 45(63.4) 71(100.0)

Manual for TB screening for Lab.

Technicians

31(42.5) 22(30.1) 20(27.4) 73(100.0)

Standard Operating Procedures

(SOPs)

34(44.7) 20(26.3) 22(29.0) 76(100.0)

Flow chart for HIV testing 31(41.3) 11(14.7) 33(44.0) 75(100.0)

HIV Lab. Manual for processing

samples, use of HIV test kits & data

management

16(21.3) 12(16.0) 47(62.7) 75(100.0)


Page 66

Table D: Availability of necessary facilities and services in the Examination room of the observed facilities,

Ethiopia, December, 2011

Facilities in Examination room Observed

n(%)

Reported, not seen

n(%)

Not available

n(%)

Total n(%)

Auditory privacy 48(66.7) 5(6.9) 19(26.4) 72(100.0)

Visual privacy 53(70.7) 3(4.0) 19(25.0) 75(100.0)

Running water 40(52.6) 3(3.9) 33(43.4) 76(100.0)

Water in bucket or basin 23(29.9) 2(2.6) 52(67.5) 77(100.0)

Hand-washing soap 37(48.7) 6(7.9) 33(43.4) 76(100.0)

Single-use hand drying towels 19(25.0) 3(3.9) 54(71.1) 76(100.0)

Sharps container 60(78.9) 3(3.9) 13(17.1) 76(100.0)

Disposable latex gloves 64(84.2) 3(3.9) 9(11.8) 76(100.0)

Disposable non-latex gloves 46(61.3) 2(2.7) 27(36.0) 75(100.0)

Already mixed decontamination

solution

37(48.7) 3(3.9) 36(47.4) 76(100.0)

Disinfectant (not yet mixed) 41(54.7) 5(6.7) 29(38.7) 75(100.0)

Condoms 62(80.5) 2(2.6) 13(16.9) 77(100.0)

Rapid test for HIV 53 (69.7) 3(3.9) 20(26.3) 76(100.0)

Examination table 67(87.0) 0(0.0) 10(13.0) 77(100.0)

Table E: Availability of facilities in laboratory units of the observed facilities, Ethiopia, December, 2011.

Facilities in Lab. room Observed

n(%)

Reported, not

seen n(%)

Not available

n(%)

Total n(%)

Running water 67(88.2) 1(1.3) 8(10.5) 76(100.0)

Water in bucket or basin (without tap) 40(56.3) 2(2.8) 29(40.8) 71(100.0)

Hand-washing soap 59(77.6) 6(7.9) 11(14.5) 76(100.0)

Single-use hand drying towels 28(36.8) 5(6.6) 43(56.6) 76(100.0)

Sharps container 76(100.0) 0(0.0) 0(0.0) 76(100.0)

Disposable latex gloves 72(94.8) 2(2.6) 2(2.6) 76(100.0)

Disposable non-latex gloves 46(63.9) 6(8.3) 20(27.8) 72(100.0)

Already mixed decontamination solution 66(86.8) 2(2.6) 8(10.5) 76(100.0)

Disinfectant (not yet mixed) 59(77.6) 3(3.9) 14(18.4) 76(100.0)

Table F: Pharmacy services of the observed facilities, Ethiopia, December, 2011.

Pharmacy service Freq. Percent

Are the antiviral stored in a locked storage unit and separate from other

medicines or supplies?

Stored alone 53 69.7

Stored with non-ARV medicines 23 30.3

Total 76 100.0

When was the last time that you received a routine supply ARVs

Within prior 4 weeks 37 48.7

Between 4-12 weeks 33 43.4

More than 12 weeks ago 6 7.9

Total 76 100.0

Have you attended the training on ARV?


Page 67

Table G: Human recourse for ART services among the observed health facilities December, 2011, Ethiopia

Qualification Health Facility Type Total

n(%) Specialized

Hospital n(%)

Regional Referral

Hospital n(%)

Zonal Hospital

n(%)

Health Centre

n(%)

Medical

Doctor

No at all 4(40.0) 0(0.0) 3(15.8) 15(83.3) 22(42.3)

Only 1 4(40.0) 3(60.0) 11(57.9) 3(16.7) 21(40.4)

2-3 2(20.0) 1(20.0) 2(10.5) 0(0.0) 5(9.6)

>=4 0(0.0) 1(20.0) 3(15.8) 0(0.0) 4(7.7)

Total 10(100.0) 5(100.0) 19(100.0) 18(100.0) 52(100.0)

Health officer

No at all 4(36.4) 3(50.0) 6(53.3) 2(6.5) 15(23.1)

Only 1 4(36.4) 1(16.4) 6(53.3) 20(64.5) 31(47.7)

2-3 3(27.3) 1(16.7) 1(5.9) 9(29.0) 14(21.5)

>=4 0(0.0) 1(16.7) 4(23.5) 0(0.0) 5(7.7)

Total 11(100.0) 6(100.0) 17(100.0) 31(100.0) 65(100.0)

BSc Nurse

No at all 5(45.5) 1(25.0) 5(35.7) 11(44.0) 22(40.7)

Only 1 2(18.2) 1(25.0) 3(21.4) 12(48.0) 18(33.3)

2-3 4(36.4) 1(25.0) 3(21.4) 2(8.0) 10918.5)

>=4 0(0.0) 1(25.0) 3(21.4) 0(0.0) 4(7.4)

Total 11(100.0) 4(100.0) 14(100.0) 25(100.0) 54(100.0)

Diploma Nurse

No at all 0(0.0) 1(20.0) 2(10.5) 1(2.9) 4(5.6)

Only 1 3(25.0) 1(20.0) 3(15.8) 11(31.4) 18(25.4)

2-3 7(58.3) 1(20.0) 7(36.8) 14(40.0) 29(40.8)

>=4 2(16.7) 2(40.0) 7(36.8) 9(25.7) 20(28.2)

Total 12(100.0) 5(100.0) 19(100.0) 35(100.0) 71(100.0)

Pharmacist

No at all 3(30.0) 0(0.0) 1(7.1) 11(57.9) 15(31.2)

Only 1 4(40.0) 1(20.0) 7(50.0) 7(36.8) 19(39.6)

2-3 1(10.0) 3(60.0) 2(14.3) 1(5.3) 7(14.6)

>=4 2(20.0) 1(20.0) 4(28.6) 0(0.0) 7(14.6)

Total 10(100.0) 5(100.0) 14(100.0) 19(100.0) 48(100.0)

Druggist

No at all 2(18.2) 0(0.0) 0(0.0) 5920.0) 7912.7)

Only 1 5(45.5) 2(33.3) 9(69.2) 13(52.0) 29(52.7)

2-3 2(18.2) 3(50.0) 1(7.7) 7(28.0) 13(23.6)

>=4 2(18.2) 1(16.7) 3(23.1) 0(0.0) 6(10.9)

Total 11(100.0) 6(100.0) 13(100.0) 25(100.0) 55(100.0)

Pharmacy

Technician

No at all 6(75.0) 3(60.0) 4(25.0) 8(27.6) 21(36.2)

Only 1 1(12.5) 1(20.0) 2(12.5) 10(34.5) 14(24.1)

2-3 1(12.5) 0(0.0) 5(31.20 11(37.9) 17(29.3)

Yes 63 87.5

No 9 12.5

Total 72 100.0


Page 68

Qualification Health Facility Type Total

n(%) Specialized

Hospital n(%)

Regional Referral

Hospital n(%)

Zonal Hospital

n(%)

Health Centre

n(%)

>=4 0(0.0) 1(20.0) 5(31.2) 0(0.0) 6(10.3)

Total 8(100.0) 5(100.0) 16(100.0) 29(100.0) 58(100.0)

Lab

technologist

No at all 2(22.2) 0(0.0) 0(0.0) 11(50.0) 13(25.5)

Only 1 3(33.3) 0(0.0) 3(20.0) 7(31.8) 13(25.5)

2-3 2(22.2) 1(20.0) 4(26.7) 4(18.2) 11(21.6)

>=4 2(22.2) 4(80.0) 8(53.3) 0(0.0) 14(27.5)

Total 9(100.0) 5(100.0) 15(100.0) 22(100.0) 51(100.0)

Lab Technician

No at all 0(0.0) 0(0.0) 0(0.0) 3(9.1) 3(4.5)

Only 1 4(40.0) 0(0.0) 0(0.0) 12(36.4) 16(24.2)

2-3 4(40.0) 3(60.0) 10(55.6) 15(45.5) 32(48.5)

>=4 2(20.0) 2(40.0) 8(44.4) 3(9.1) 15(22.7)

Total 10(100.0) 5(100.0) 18(100.0) 33(100.0) 66(100.0)

Data clerk

No at all 1(8.3) 0(0.0) 0(0.0) 1(2.8) 2(2.7)

Only 1 3(25.0) 1(16.7) 4(21.1) 33(91.7) 41(56.2)

2-3 7(58.3) 3(50.0) 15(78.9) 2(5.6) 27(37.0)

>=4 1(8.3) 2(33.3) 0(0.0) 0(0.0) 3(4.1)

Total 12(100.0) 6(100.0) 19(100.0) 36(100.0) 73(100.0)

Case manager

No at all 1(10.0) 1(20.0) 0(0.0) 2(6.7) 4(6.2)

Only 1 6(60.0) 1(20.0) 10(52.6) 26(86.7) 43(67.2)

2-3 2(20.0) 3(60.0) 6(31.6) 2(6.7) 13(20.3)

>=4 1(10.0) 0(0.0) 3(15.8) 0(0.0) 4(6.2)

Total 10(100.0) 5(100.0) 19(100.0) 30(100.0) 64(100.0)

Expert patient

No at all 2(25.0) 1(20.0) 1(9.1) 7(43.8) 11(27.5)

Only 1 0(0.0) 1(20.0) 1(9.1) 4(25.0) 6(15.0)

2-3 1(12.5) 1(20.0) 5(45.5) 4(25.0) 11(27.5)

>=4 5(62.5) 2(40.0) 4(36.4) 1(6.2) 12(30.0)

Total 8(100.0) 5(100.0) 11(100.0) 16(100.0) 40(100.0)


Page 69

Annex III Exit interview among selected ART clients during the study period

Table H: Selected background characteristics of ART users exit interview respondents, Oct-Dec 2011,

Ethiopia

Variable N Percent

Region

Tigray (1) 165 13.6

Amhara (3) 321 26.4

Oromiya (4) 314 25.8

B/Gumuz (6) 25 2.1

SNNPR (7) 148 12.2

Dire Dawa (9) 59 4.9

Gambella (12) 8 0.7

Harai (13) 22 1.8

Addis Ababa (14) 154 12.7

Total 1216 100.0

Facility ownership

Public 1205 99.3

Private 1 0.1

NGO 7 0.6

Total 1213 100.0

Type of facility

Specialized Hospital 151 12.4

Regional Referral Hospital 429 35.3

Zonal/District Hospital 355 29.2

Health Centre 285 23.4

Total 1216 100.0

Sex of respondent

Male 501 41.4

Female 710 58.6

Total 1211 100.0

Age of respondents

15-19 22 1.9

20-34 605 50.6

>=35 568 47.5

Total 1195 100.0

Marital Status

Single 213 17.6

Married 622 51.5

Divorced 138 11.4

Widowed 174 14.4

Separated 61 5.0

Total 1208 100.0

Religion

Orthodox 859 71.3


Page 70

Variable N Percent

Muslim 190 15.8

Protestant 156 12.9

Total 1205

Residence

Rural 226 18.7

Urban 981 81.3

Total 1053 100.0

Educational status

No education 353 29.4

Primary (Grade 1-8) 445 37.1

Secondary (9-12) 301 25.1

Tertiary (> 12) 101 8.4

Total 1200 100.0

Occupation

Unemployed 181 15.7

Student 48 4.2

Employed 236 20.5

Daily laborer 187 16.3

Merchant 157 13.7

Housewife 166 14.4

Farmer 151 13.1

Other** 24 2.1

Total 1150 100.0

Perceived health status

Poor 35 2.9

Fair 150 12.5

Good 565 47.2

Very Good 322 26.9

Excellent 125 10.4

Total 1197 100.0

* Total exit interview participants were 1062, the difference of the total for each variable is accounted for missing

values

**Driver, mining worker, pension, prisoner


Page 71

Table I: Access to health facility for ART use among exit interview participants, Oct-Dec, 2011, Ethiopia

Variables Freq. Percent

Distance from Health facility (in Kms)

<=5 677 61.4

6-10 168 15.2

11-15 48 4.4

16-20 40 3.6

>20 169 15.3

Total 1102 100.0

Means of transportation

On foot 570 48.5

Vehicle 606 51.5

Total 1176 100.0

Had been in other facility for ART

Yes 196 16.5

No 991 83.5

Total 1040 100.0

How came

Transferred with document 147 75.0

Without any notice 49 25.0

Total 196 100.0

Reason for coming without notice

Job 14 35.0

Unsatisfied with the service 12 30.0

Discontinued Rx for sometime 7 17.5

Stigma 7 17.5

Total 40 100.0

Table J: Clients‟ view on the process of Client-provider interaction during ART service provision, Oct-Dec,

2011, Ethiopia

Questions Never (1) n(%) Rarely (2)

n(%)

Sometimes(3)

n(%)

Most Times (4)

n(%)

All of the Time

(5)

n (%)

Total

n(%)

How often your providers explain

the side effects of your HIV

medications?

52(4.3) 60(5.0) 150(12.4) 430(35.6) 516(42.7) 1208

(100.

0)

How often your providers help

you remember to take your HIV

medications?

17(1.4) 47(3.9) 163(13.5) 451(37.3) 530(43.9) 1208(

100.0

)


to you medical tests you should

be getting?

50(4.1) 80(6.6) 185(15.3) 411(34.0) 482(39.9) 1208(

100.0

)


Page 72


to you how to stay healthy?

23(2.6) 35(4.0) 92(10.6) 278(32.0) 442(50.8) 870(1

00.0)

How often your providers talk to

you how to avoid transmitting

HIV to others?

34(2.8) 58(4.8) 160(13.3) 396(32.8) 558(46.3) 1206

4

(100.

0)

Table K: Client satisfaction to ART services, Oct-Dec 2011, Ethiopia

Satisfaction questions Yes

n(%)

No n(%) Total

n(%)

Are you satisfied with reception?

1079(89.1)

132(10.9) 1211(100.0)

Are you satisfied with physical examination?

1078(88.9)

135(11.1) 1213(100.0)

Are you satisfied with laboratory examination?

960(79.5)

248(20.5) 1208(100.0)

Are you satisfied with pharmacy service?

1099(91.0)

109(9.0) 1208(100.0)

Are you satisfied with waiting time?

910(75.1)

302(24.9) 1212(100.0)

Are you satisfied with privacy?

1094(91.1)

107(8.9) 1201(100.0)

Are you satisfied with facility distance?

918(76.0%)

290(24.0%) 1208(100%)

At any point, did you feel treated poorly at this clinic?

202(16.7)

1010(83.3) 1212(100.0)

Have you thought leaving this clinic to find better care

somewhere else?

188(15.6)

1016(84.4) 1204(100.0)

Table L: Clients’ perspective concerning general quality of the ART services, Oct-Dec, 201,

Ethiopia

Did the staff and your providers kept your HIV status confidential Freq. Percept

Yes 842 69.9

No 77 6.4


Page 73

I don‟t know 286 23.7

Total 1205 100.0

Have you ever not got the medical care you needed because you could

not pay for it?

Yes 300 25.3

No 886 74.7

Total 1186 100.0

How would you rate the overall quality of care at this clinic?

Very poor 43 3.6

Poor 31 2.6

Fair 99 8.2

Good 700 57.9

Very good 335 27.7

Total 1208 100.0

Would you recommend this clinic to your friends with similar needs?

Yes 1020 87.6

No 145 12.4

Total 1165 100.0

What is your feeling about the separate clinic for ART?

Agree 1123 93.6

Disagree 77 6.4

Total 1200 100.0

REFERENCE

1. CSA. Ethiopia Population and Housing Censes (2007) projection for 2012. Addis Ababa, Ethiopia,

Central Statistical Authority.

2. Federal Democratic Republic of Ethiopia Ministry of Health. Health Sector Development

Programme IV 2010/11 – 2014/15. , Addis Ababa. FMOH. 2010.

3. Ethiopian Health and Nutrition Research Institute Federal Ministry of Health.HIV Related

Estimates and Projections for Ethiopia. (2012). Addis Ababa, Ethiopia

4. CSA and ORC Macro. Ethiopia Demographic and Health Survey 2011, Addis Ababa, Ethiopia,

and Calverton, Maryland, USA: Central Statistical Authority and ORC Macro. 2011.

5. Multi-sectoral HIV/AIDS monitoring and evaluation progress report for EFY 2004

6. Eleni Seyoum, Yared Mekonnen, Afework Kassa et al. ART scale-up in Ethiopia: Success and

challenges. Federal HIV/AIDS Prevention and Control Office (HAPCO). 2009.

7. HIV/AIDS Country progress report of 2012. Federal HIV/AIDS prevention & Control Office

8. FMOH-HAPCO. Guidelines For HIV Care/ART Clinical Mentoring in Ethiopia. 2007.

9. FMOH-HAPCO. Guidelines For Paediatrics HIV/AIDS Care and Treatment in Ethiopia. July

2008.


Page 74

10. FMOH-HAPCO. Guidelines For Management of Opportunistic Infections and ART in

Adolescents and Adults in Ethiopia. 2007.

11. Rochelle P, Walensky, Lindsey L, et al. When to Start Antiretroviral Therapy in Resource-limited

Settings. Ann Intern Med 2009; 151(3): 157–166.

Federal HIV/AIDS Prevention and Control Office

P.O.Box 122326

Addis Ababa, Ethiopia

Tel. +251-0115547958/59

Anti-retroviral Treatment Implementation Status & Outcome ...

Documents

Transcript of Anti-retroviral Treatment Implementation Status & Outcome ...